ijpot oct-dec-2011

Indian Journal of

Physiotherapy and Occupational Therapy An International Journal

ISSN P - 0973-5666ISSN E - 0973-5674

Volume 5 Number 4 October - December 2011

website: www.ijpot.com

INDIAN JOURNAL OF PHYSIOTHERAPY ANDOCCUPATIONAL THERAPY

EditorDr. Archna Sharma (PT)

Head, Dept. of Physiotherapy, G.M. Modi Hospital, Saket, New Delhi 110 017E-mail: [email protected]

Executive EditorDr. R.K. Sharma

Dean, Saraswathi Institute of Medical Sciences, Ghaziabad (UP)Formerly at All-India Institute of Medical Sciences, New Delhi

National Editorial Advisory BoardProf. U. Singh, New DelhiDr. Dayananda Kiran, IndoreDr. J.K. Maheshwari, New DelhiDr. Suraj Kumar, New DelhiDr. Renu Sharma, New DelhiDr. Veena Krishnananda, MumbaiDr. Jag Mohan Singh, PatialaDr. N. Padmapriya, ChennaiDr. G. Arun Maiya, ManipalProf. Jasobanta Sethi, BangaloreProf. Shovan Saha, ManipalProf. Narasimman S., MangaloreKamal N. Arya, New DelhiDr. Nitesh Bansal, NoidaDr. Aparna Sarkar, NoidaDr. Amit Chaudhary, FaridabadDr. Subhash Khatri, BelgaumDr. S.L. Yadav, New DelhiDr. Sohrab A. Khan, Jamia Hamdard, New DelhiDr. Dheeraj Lamba, HaldwaniDr. Deepak Kumar, New DelhiDr. Kalpana Zutshi, New Delhi

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Dr. Smiti, CanadaDr. T.A. Hun, USA

Heidrun Becker, GermanyRosi Haarer Becker, Germany,

Prof. Dra. Maria de Fatima Guerreiro Godoy, BrazilDr. Venetha J. Mailoo, U.K.

Dr. Tahera Shafee, Saudi ArabiaDr. Emad Tawfik Ahmed, Saudi Arabia

Dr. Yannis Dionyssiotis, GreeceDr. T.K. Hamzat, Nigeria

Prof. Kusum Kapila, KuwaitProf. B.K. Bhootra, South Africa

Dr. S.J. Winser, MalaysiaDr. M.T. Ahmed, Egypt

Prof. Z.W. Sliwinski, PolandDr. G. Winter, Austria

Dr. M. Nellutla, RwandaProf. GoAh Cheng, Japan

Dr. Sema Oglak, TurkeyDr. M. Naveed Babur, Pakistan

Print-ISSN: 0973-5666 Electronic - ISSN: 0973-5674, Frequency: Quarterly (4 issues per volume).“Indian journal of physiotherapy and occupational therapy” An essential indexed double blind peer reviewed journal for all Physiotherapists & Occupational therapists provides professionals with a forum to discuss today’s challenges - identifying the philosophical and conceptual foundations of the practics; sharing innovative evaluation and tretment techniques; learning about and assimilating new methodologies developing in related professions; and communicating information about new practic settings. The journal serves as a valuable tool for helping therapists deal effectively with the challenges of the field. It emphasizes articles and reports that are directly relevant to practice. The journal is now covered by INDEX COPERNICUS, POLAND. The journal is indexed with many international databases, like PEDro (Australia), EMBASE (Scopus) & EBSCO (USA) database. The journal is registered with Registrar on Newspapers for India vide registration DELENG/2007/20988. The Journal is part of UGC, DST and CSIR consortia.

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Contentswww.ijpot.com

October - December 2011Volume 5, Number 4

Indian Journal of Physiotherapy and Occupational Therapy. October - December. 2011, Vol. 5, No. 4

1 The Effect of Proprioceptive and Strengthening Exercises in Knee OsteoarthritisAastha Maggo, Shobhit Saxena, Shalini Grover

6 Cervicogenic Dizziness: Implications for Physical TherapyAmer A AlSaif, Eric G Johnson

12 Randomised Controlled Study of Mulligan’s Vs. Maitland’s Mobilization Technique in Adhesive Capsulitisof Shoulder JointAnkit Shrivastava, Ashok K Shyam, Shaila Sabnis, Parag Sancheti

16 Home Environment as a Correlate of Development of Toddlers in BangaloreS Balsubramanian, Y S Siddegowda

21 A Study of Efficacy of Neuromuscular Electrical Stimulation in Post Anterior Cruciate LigamentReconstructionBibek Adhya, Pravin Yadav, M. S. Dhillon, Vijay Kumar, Upendra Goswami

24 Effect of Two Different Exercises Protocol For Fall Preventation in ElderlyChaitali Shah, Vaishali Suthar

29 Functional Performance in Community-dwelling Elderly People: Six-minute Walk Test, Berg BalanceScale, Timed Up and Go Test and Gait SpeedsGarg Chaya, Sindwani Vidhu

34 A Case Report on the Role of Occupational Therapy in Revascularised and Replanted Surgical Case ofFlexor Tendon of HandDeepak Ganjiwale

36 Effect of Keyboard Slope and Forearm Support on User Performance and Comfort LevelDheeraj Lamba, Babita Mishra, Neetu Arya, Shammi Chetan, Saloni Priya

40 Effect of Deep Cervical Flexor Strengthening on Vertical Mandibular Opening on Subjects With ForwardHead PostureDheeraj Lamba, Satish Pant, Girish Chandra, Asha Joshi, Divya Dalakoti

44 Effects of Limb Dominance on Cross TrainingDheeraj Lamba, Heena Maheshwari, Kavita Kandpal, Babita Mishra, Preeti Joshi

48 Relationship Between Motor Impairments of Hand and Manual Ability in Spastic Cerebral Palsy ChildrenGagandeep Kaur, Poonam Mehta, Chandan Kumar

53 Discriminant Ability of Gravitational Insecurity (GI) AssessmentU Ganapathy Sankar, A Prema

56 Effect of Therapist Applied PNF Stretch Vs Self Applied PNF Stretch on Hamstring Flexibility in YoungMalesGaneswara Rao Melam, Syamala Buragadda, B Praveen Kumar

60 Normative Values for Maximal Respiratory Pressures in Subjects Age 20 to 70 Years. A Cross-sectionalStudyGopala Krishna Alaparthi, Vaishali, V Prem, Jaya Shanker Tedla, Kalyana Chakravarthy, Ravi Shankar Y

64 Management of Patients With Concurrent Hypertension and Osteoarthritis of the Knee: ComparativeEffect of Using Non Steroidal Anti Inflammatory Drugs and Physical TherapyTalhatu K Hamzat, Adeolu O Ajala, Fatai A Fehintola

69 Comparing Effectiveness of Antero-Posterior and Postero-Anterior Glides on Shoulder Range of Motionin Adhesive Capsulitis - A Pilot StudyHarsimran K, Ranganath G, Ravi SR

73 Effect of Head Down Tilt on Hemodynamics in Valve Replacement Surgery PatientsAjit Thomas, Jamal Ali Moiz, Amit Banerjee

77 Efficacy of Motor Relearning Programme on Physical Performance and Weight Bearing on the LowerLimbs in Sitting Position in Post Stroke Hemiparetic SubjectsJatinder Pal Kaur, Senthilkumar CB, Venkadesan R

83 The Effect of Low Power Laser Acupuncture on Experimental Pain Threshold in Normal Subjectswith Lung Pathology- A randomised cross over studyJavan Amoli M, Ebrahimi I, Marofi N, Javan Amoli M

87 Influence of Graded Aerobic Exercise in Post-surgical Adult Acyanotic Congenital Heart Disease - AProspective Randomized Clinical TrialK Madhavi, Abhachandra, Arun G maiya

95 Efficacy of Mirror Therapy on Motor Recovery of Hand Functions in Sub Acute Stroke Individuals-aRandomized Controlled TrialKusumalatha Nookala, Srikumari Vadlamudi

101 Effect of Unilateral and Bilateral Auricular Acupuncture Like TENS on Pain ThresholdMalik Manoj, Kaur Jaspreet

108 Correlation of Body Mass Index to the Fasting Blood Sugar in Young Adult PopulationMaliyannar Itagappa, Vasudeva Murthy C R

111 To Compare the Effects of High and Low Frequency Transcutaneous Electrical Nerve Stimulation onAcupuncture Points in Experimental Pain ThresholdManish Jain, Nidhi Sharma, Sumit Kalra

115 Assessment of Motor Function in Multiple Sclerosis Patients Treated with MethylprednisoloneFrank van Eijkeren, Ruud Reijmers, Erik van Munster, Mirrian Hilbink

119 Test-retest Reliability of the Onset of Lower Limb Muscles’ Preactivation During Landing from A Jump inVolleyball Players With Functional Ankle InstabilityMohammad Sadeghi Goghari, Smaeil Ebrahimi, Nader Maroufi, Ali Ashraf Jamshidi

122 Evaluation of Wet Cupping Therapy (Hijama) as an Adjuvant Therapy in the Management of BronchialAsthmaMohamed Elsayed Mohamed Abd al-Jawad, Adel Mohamed Saeed, Ahmed Elsayed Badawy, Nevine M MohamedAbd Elfattah

127 Comparative Analysis of Muscle Energy Technique and Conventional Physiotherapy in Treatment of SacroiliacJoint DysfunctionMullai Dhinkaran, Aarti Sareen Tanu Arora

131 Importance of Neural Biomechanics for Under Graduate Students of Physiotherapy – A Descriptive StudyN A Ramasubramania Raja

135 Comparing the Effectiveness of Lumbar Stabilization Exercises with General Spinal Exercises in Patientswith Postero-lateral Disc HerniationsMuhammad Naveed Babur, Danyal Ahmed, Farah Rashid

138 Comparsion of Efficacy Between Simple and Complex Plyometrics Training on Concentric HamstringTorque, Angular Velocity and Power using Isoinertial DynamometerN P Singh

142 Translation and Adaptation of Shoulder Pain and Disability Index (SPADI) into Hindi-Part 1Neha Sharma, Shallu Sharma, Chitra Kataria

146 Comparision of Musculoskeletal Symptoms Among Adult Female Caregivers of Physically ChallengedChildren and Normal ChildrenParul Raj, Amitesh Narayan, Sailakshmi Ganesan

150 A Comparative Study of Left and Right Hand Grip Strength in Different Positions of Shoulder and ElbowPrashant B Mukkannavar, Umasankar Mohanty

155 Correlation Between the Counting Talk Test and Body Mass Index in Young AdultsPreeti Chauhan, Pinki Bhasin

159 Comparsion of the Depressive Symptoms and Physical Performance in Mothers of Disabled and Non-disabled ChildrenRasmi Muammer, Kiymet Muammer, Yasemin C Yildirim,Osman Hayran

163 Assessment of Maximal Inspiratory Mouth Pressure in Healthy Individuals of Different Age Group: NormalValuesRavi Savadatti, Gajanan S Gaude, Prashant Mukkannavar

167 Physiotherapy Management of Chronic Back Pain: Systematic Literature ReviewAcharya Ranjeeta, AL-Oraibi Saleh

171 A Comparative Study to Ascertain Differences Between Rheobase, Girth and Isometric Strength AmongstDominant and Non Dominant Upper Limb in Normal SubjectsShivani Chowdhury Salian, Sujata Yardi, Vinita P. Kadam

176 Physiological Quadriceps LagShweta Basu Roy, Sona Kolke

181 Effect of Play Therapy on Functional Reach in Stroke CasesSurinder Pal Singh

185 Effect of Deep Transverse Friction Massage and Capsular Stretching in Idiopathic Adhesive CapsulitisVaishali Chauhan, Shobhit Saxena, Shalini Grover

Indian Journal of Physiotherapy and Occupational Therapy. October - December. 2011, Vol. 5, No. 4

1Aastha Maggo / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

The Effect of Proprioceptive and Strengthening Exercises in KneeOsteoarthritisAastha Maggo, Shobhit Saxena, Shalini GroverDepartment of Physiotherapy, Faridabad Institute of Technology, Faridabad, Haryana

Abstract

Study Design

The study was a randomized controlled trial.

Objective

To compare the effectiveness of proprioceptive exercisesand strengthening exercises in treatment of osteoarthritis of kneein terms of pain and functional disability.

Background

Few investigations include both strengthening andproprioceptive exercises in the treatment of knee osteoarthritis.Though previous studies give us some insight in to the role ofproprioceptive exercises in knee OA but none of the studieshave studied the combined effect of strengthening exercisesand proprioceptive exercises in knee OA. Thus, it is intended tocheck the efficacy of proprioceptive and strengthening exercisesin knee OA to reduce pain and functional disability and improvejoint position sense.

Methods

In this study 24 subjects who met the inclusion criteriawere randomized into three groups three groups. Group A weregiven conventional treatment (SWD and staticquadriceps).Group B were given strengthening exercises alongwith SWD. Group C; which were given strengthening exercisesand proprioceptive exercises along with SWD. Outcomemeasures were pain, functional disability and joint positionsense.

Results

All the groups significantly improved in VAS and WOMACscores after intervention pd”.05, knee reposition error score(Joint position sense) only improved in proprioceptive exercisesgroup. The proprioceptive exercises group demonstrated greaterimprovement in VAS and WOMAC scores as compared to othertwo groups.

Conclusion

This study between three groups comparing conventionaltreatment to strengthening and proprioceptive exercises suggestthat combination of the two brings better relief to the subjects ofknee OA in reducing pain and functional disability.

Introduction

Osteoarthritis (OA) is the most common joint disorder, aprevalence that increases with age and sex specifications2,3.Among adults 45-74 years of age or older, symptomatic diseaseoccurs in approximately 12.1% population4.Before 50 years ofage the prevalence of OA in most joints is higher in men than in

women. After about 50 years of age, women are often affectedwith hand, foot and knee OA than men3. In subjects with no jointpain who have radiographic changes of OA, quadricepsweakness predicts radiograph progression and pain6.Thesefindings suggest that the weakness may occur before arthriticdamage.

Nevertheless, exercises to strengthen the quadricepsrelieve joint pain in persons with OA of knee7. The strengtheningexercises are beneficial for knee OA by several pathways,improving strength, improving psychological well-being. All ofthese may interact and have an additive effect on the symptomsof OA7.Barret et al, (1991) has reported impaired proprioceptionfor the patients suffering from knee osteoarthritis. Fewinvestigations have investigated the relationship betweenimpaired proprioception and performance or other measures offunctional status in OA. In addition Birmingham et al, (2001)stated that quadriceps sensory dysfunction that is, decreasedproprioceptive acuity, has recently been demonstrated in patientswith knee OA and proposed as a factor in the pathogenesis orprogression of the condition. If correct, restoration of thesesensorimotor deficits with strengthening may retard progressionof knee OA and reduce disability. Although it is generallyaccepted that a rehabilitation program improves the functionalcapacity, pain and sensoriomotor function of patients, there islack of agreement about what such a rehabilitation programshould include (Roddy et al., 2005). Many previous studies havegenerally used sophisticated and expensive apparatus, whichlimits their application to a community setting 8,9,10.Though theabove mentioned studies give us some insight in to the role ofproprioceptive exercises in knee OA but none of the studieshave studied the combined effect of strengthening exercisesand proprioceptive exercises in knee OA. Thus, in this study itis intended to check the efficacy of proprioceptive andstrengthening exercises in knee OA to reduce pain, functionaldisability and improve joint position sense.

Patients and Methods

Under convenience sampling, 32 subjects were recruitedfrom the physiotherapy department of Sanjay Gandhi MemorialHospital (Delhi). The subjects were screened by means of ascreening form one of the three groups- group A (conventionaltreatment group), group B (strengthening exercise treatmentgroup) and group C (strengthening exercise and proprioceptiveexercise) by simple randomization method.

Inclusion Criteria

1. Diagnosed cases of osteoarthritis grade 2 and 3 (Asreported by radiologist).

2. Age group-45 to 60 years.3. Bilateral osteoarthritis.4. Gender-both male and female5. Patients should able to demonstrate sufficient English skills.

Exclusion Criteria

1. Neurologic disorder (e.g. Parkinson’s disease, Alzheimer’sdisease)

2. Steroid injection in past 2 months

3. Inflammatory arthritis4. Metal implants in lower limb5. Osteoporosis6. Knee ligament/Meniscal injury

Group A received short wave diathermy and staticquadriceps exercise, Group B received short wave diathermyand strengthening exercises and Group C received short wavediathermy, strengthening exercises and proprioceptive exercises.

Intervention

1. Before starting the exercises, patients were given treatmentfor pain reduction by short wave diathermy. The patientswere positioned supine and comfortably on the treatmentplinth. Patient in each group received 20 min of SWD thricea week for four weeks (12 treatments) applied by malleableelectrodes by contraplanar method (Chitra, 2007)11. Theintensity of the SWD was based on each subject’s tolerancebut all the subjects were advised that they should feel justcomfortable warmth (Low and Reed, 2000).

2. Strengthening exercises (Gail D,2005)12Static quadricepsin knee extension- Patient is positioned fully supine. Patientcontracts the quadriceps femoris muscle and pushes kneedown while maintaining the foot in full dorsiflexion, eachcontraction is held for 6 sec with a 10 sec rest betweenrepetitions. 10 repetitions are done.

Standing terminal knee extension- Patient stands with aresistive band behind a slightly flexed knee. Patient contractsthe gluteal and quadriceps femoris muscle to fully straightenthe hip and knee. Each contraction is held for 3 seconds, 10repetitions were done and resistance is increased as toleratedby the patient.

Closed chain exercise, one of the two exercises isperformed 3 times per week. Patient should progress to themost challenging activity that he or she can successfullycomplete with minimal or no pain.a. Seated leg press- Patient is seated holding a resistive band

in both the handsA patient places his or her foot against the band, thenstraightens the knee by straightens the knee by pushingthe foot down and forward by contracting the gluteal andquadriceps femoris muscles. Each contraction is held for 3seconds with knee as straight as possible, patient slowlyreturn to the starting position and repeat for 30 sec bout.Progression is made by using bands of high resistance andadditional bouts.

b. Partial squats - Patient stands with arm support as needed,patient performs a partial squat, keeping the knees centeredover the feet return to standing by contracting thequadriceps femoris and gluteal muscles. Each contractionis held for 3 seconds with hips and knees as straight aspossible. Progress to full body weight without support andadditional bouts.

3. Proprioceptive exercises. (Chita et al, 2007)11

a. One leg balance-it involved standing on affected foot withrelaxed upright posture and other leg flexed at knee, hipand ankle, this position was held for one minute followedby rest for 10 to 20 seconds and was repeated twice more.After a brief rest three similar repetitions were carried outfor unaffected leg(Fig a).

b. Blind advanced one leg balance-It was same like one legbalance, expect that the patient was asked to keep his/hereyes completely closed while performing the routine, andthen was repeated twice again (Fig b).

c. Toe walking-Here the patient was made to walk for 20meters high up on the toes with toes pointing straight ahead,then walk with toes pointing outwards and then walk with

toes pointing inwards after a short rest repeat it onceagain(Fig c)

d) Heel walking - Walking for 20 meters on heels with toespointing straight ahead, walking on heels with toes pointingout and walking on heels with toes pointing in. After a shortrest, the procedure was repeated once more(Fig d)

e) Cross leg body swing-Leaning slightly forward with handson wall for support and weight on affected leg, other legwas swung in front of the body pointing toes upwards asfoot reaches its farthest point of motion. Then swing thisunaffected leg back to the unaffected side as far ascomfortably possible, again pointing toes up as foot reachesits final point of movement. Repeat this overall motion 15

(e)

(c) (d)

(a) (b)

Aastha Maggo / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

times with erect body posture and good balance, rest for afew seconds, and then 15 similar repetitions with theunaffected leg as weightbearing limb was performed (Fige).Treatment was given three times per week for four weeks.In this study the outcome measures were-:

All outcome measures were measured at baseline, end of week1, end of week 2, end of week 3 and end of week 4.

Pain – was measured using the visual analogue. Functionaldisability-was measured using the Western Ontario andMcMaster Universities Osteoarthritis Index (WOMAC) Jointposition sense-was measured using inclinometer by Repositionerror test (Higgins and Perrin, 2000).

Procedure for reposition error test- all the subjects werefamiliarized with the procedure by explanation, demonstrationand adequate practice repetition. Inclinometer was attached tothe distal thigh of dominant extremity approximately one inchabove knee joint line. Patient is standing with back against walland is blindfolded to eliminate visual cues, Patient squats to 30degree of knee flexion and maintains this position for 15 sec,return to starting position of 0 degree extension, Following a 15sec rest period patient then attempts to reposition themselvesat the predetermined angle, degree of error from 30 degree kneeflexion target angle is recorded and average over three trials isused for data analysis (Higgins and Perrin, 2000)13.

Inclinometer for assesing joint position sense(Repositionerror test)

Statistical Analysis

A total of 32 patients were screened for possible studyeligibility. 28 patients satisfied the eligibility criteria, were recruitedinto study and underwent baseline measurement. Four patientsin this study did not complete the treatment. There were twodropouts from Group A, one each from Group B and Group C.Total of 24 subjects, including both males and females,completed the study. Age of subjects in this study was between45-60 years. The mean age of subjects in Group A was51.5(±4.30) years, Group B was 49.5(±2.44) years, and GroupC was 51.62 (±3.96) years. There was no significant differencebetween the mean ages of all the three groups. Group A had 5

females and 3 male patients, Group B had 6 females and 2male patients, Group C had 6 female and 2 male patients. Intotal there were 17 female and 9 male patients.

Readings of the variables taken at the baseline and at theend of first , second , third and fourth week were analyzed forintragroup differences using repeated measure ANOVA andpaired samples t-test with Bonferroni correction. Intergroupdifferences were analyzed using one way ANOVA.

For intergroup differences result was considered significantif p value d” 0.05 and for intragroup differences result wasconsidered significant if p-valued”0.01.

Results

Within Group Analysis of pain scores - The repeatedmeasures ANOVA results for VAS scores revealed a significantdifference within all groups.

Between group analysis of pain scores - The analysis ofVAS scores Between all the groups suggested that there wereno significant differences at the baseline (p=0.397) and at theend of 1st week (p=0.052).At the end of 2nd week there wassignificant difference between the groups (p=0.002), at the endof 3rd week there was significant difference between the groups(p=0.000), at the end of 4th week there was significant differencebetween the groups (p=0.000).

Within Group Analysis of WOMAC scores-the results ofrepeated ANOVA and post-hoc t-test showed significantdifferences in WOMAC scores in all the groups.

Between group Analysis of WOMAC Scores-The analysisof WOMAC score between the groups suggested that there wereno significant differences between baseline (p=0.110) and week1(p=0.467).At the end of 2nd week there was significant differencebetween the groups (p=0.003). At the end of 3rd week therewas significant difference between the groups (p=.000). At theend of 4th week there was significant difference between all thegroups (p=.000).

Graph 1: Comparison between mean values of VAS

Graph 2: Comparison of mean values of WOMAC


4

Within Group Analysis of Reposition Error Test scores -The results of repeated ANOVA and post-hoc t-test showed nosignificant differences in Reposition scores in group A and B.But in Group C there was statistically significant improvementin baseline and week 4.

Between Group Analysis of Reposition error test - Theanalysis of reposition error score between the groups suggestedthat there were no significant differences between baseline(p=0.193), week1 (p=0.144), week2 (p=0.135), week 3 (p=0.095)and week 4 (p=0.113).

Graph 3: Comparison of mean values of Reposition error scores

Graph 4: Comparison of percentage improvements in alloutcome measures

Table 1: Percentage of improvement in all outcome measures across the three groups

Outcome measure Percentage of improvementGroup A Group B Group C(conventional (strengthening (strengthening and treatment) exercises) proprioceptive

Exercises)

Pain(VAS) 24.64% 35.72% 44.71%

Disability(WOMAC) 41.03% 57.60% 68.48%

Joint position sense(RET) 2.70% 3.08% 9.35%

Discussion

The purpose of this study was to determine theeffectiveness of Proprioceptive exercises along withstrengthening exercises in improving pain and disability inpatients with knee osteoarthritis. In all the three groups- pain,disability and joint position sense were taken as the dependentvariables to assess the improvement between the groups andwithin the group. The findings of the present study suggest thatthe addition of proprioceptive exercises and strengtheningexercises reduces patient’s pain and disability more effectivelythan strengthening exercises or conventional physiotherapyalone over a 4 week period. Statistical analysis revealed nosignificant differences in key demographic variables and baselinemeasurements of pain, disability and active angle replicationtest suggesting that all the groups had homogenous distributionof patients.

In this study VAS was used to measure pain. A statisticallysignificant difference was found between all the groups.Maximum reduction of pain was in group C (37±0.02mm). Thisis in favor of our research hypothesis. Pain relief in this group isin accordance with a case report of 70 year old lady withosteoarthritis of knee who found moderate pain relief byproprioceptive exercises as done by Childs et al(2002)14.Reduction in pain in Group A (conventional treatment) and B(strengthening exercise group) is consistent with previousfindings which state that both dynamic and isometric resistancetraining reduced perceived knee joint pain15.Proprioceptivetraining activities provide patient with an opportunity to adaptto potentially destabilizing loads on the knee during rehabilitation,give additional exposure to pivoting, quick starting and stoppingand quick changes in direction and challenge their balancecapabilities. Strengthening exercises are recommended toreduce pain and improve physical function in knee OA, but thereis minimal information on its long term impact8.It is theorizedthat because elevated plasma â endorphin, a neuro transmitterinhibitory to pain signal, has been observed in response toprolonged rhythmic exercise (Thoren et al, 1990) leading toincreased â endorphin production might decrease painexperienced by persons with osteoarthritis17.

In the present study WOMAC Score was used to assesoverall knee function since its validity and reliability is alreadyestablished16. The analysis of disability score reveals nosignificant difference at baseline. There was significantimprovement in Group B (Strengthening exercises) and C(Strengthening exercise and Proprioceptive exercises) ascompared to Group A(conventional treatment ) but maximumdifference in mean score of Group C (52 mm), supporting our

research hypothesis. Both the treatment groups A and B resultedin significant improvements in all the variables compared to theconventional therapy group. A study by Felson et al (2009) statesthat proprioceptive acuity as assessed by the accuracy ofreproduction of the angle of knee flexion has modest effects onpain and physical function limitation in knee osteoarthritis. Thiscould be due to pain relief, reduction in stiffness, increasedlubrication of joint, gain in strength of weak muscles, correct

mechanical loading, improved joint stability and thus increasedquality of movement and improved proprioception which in turnprovides participants an opportunity to adapt to potentiallydestabilizing load on knee during the study period9. Hurley et al(2004) have reported that proprioception is closely related tofunctional performance and walking speed. This is in accordancewith this study which shows greater mean difference inproprioceptive exercises group than with other two groups.


5

In this study joint position sense was measured by repositionerror test (RET).The analysis of RET at baseline reveals nosignificant differences between all the three groups. At the endof 4th week mean differences were not significant between allthe groups. There was improvement in all the groups whichsupports the study that proves general exercise training canincrease proprioceptive performance (Bernauer et al,1994).Maximum reduction in mean was in Group C (0.48°). Thedifference between the moderate improvement in other twogroups as compared to Group C and greater improvement inthis group was probably due to specific proprioceptive exercises.Proprioceptive information alone (without visual feedback) cancorrect up to 95% of velocity and timing errors associated withsudden perturbation in resistance during a multi-joint movementsequence10.

Group A (conventional treatment), Group B (strengtheningexercises) and Group C (proprioceptive and strengtheningexercises) does not show any statistically significant differenceat the end of 4 week study period. This is in accordance with astudy done by Sekir et al, 2005 in which 6 weeks of proprioceptiveand balance training was given to treatment group while thecontrol group did not receive any exercise but there was nosignificant differences by the end of training in weight bearingjoint position sense. Therefore, it may be concluded thatproprioceptive acuity takes longer duration to show significantimprovement.

Sample size was small and data was collected from limitedplace that limits the generalizability of the results. The durationof study was short (4 weeks) therefore long term effectivenessof proprioceptive exercises was not evaluated. Neither thesubjects nor the therapist were blinded to group assignment.The cohort of patients with knee osteoarthritis werepredominately female, hence generalizability of our findings maynot necessarily be applicable to the entire population ofindividuals with osteoarthritis.

This study showed that patients affected with OA knee,when performed proprioceptive exercises along withstrengthening exercises showed significant reduction in pain andfunctional disability and improvement in proprioception ascompared to patients performing strengthening exercises alone.Thus proprioceptive exercises can be incorporated along withstrengthening exercises in patients of knee osteoarthritis.

Conclusion

Management of osteoarthritis, which deteriorates withimbalance between the stress applied to the articular cartilageof the joint and its ability to withstand it, requires being moreextensive than mere analgesics. This study between threegroups comparing conventional treatment to strengthening andstrengthening and proprioceptive exercises suggest thatcombination of the two (proprioceptive and strengtheningexercises) brings better relief to the subjects of kneeosteoarthritis in reducing pain and functional disability. However,reposition error scores (joint position sense) did not improvesignificantly in proprioceptive and strengthening exercise groupthan other two groups. These results partly accept and partlyreject the experimental hypothesis suggesting that usingproprioceptive exercises and strengthening exercises togetherwill produce statistically significant difference in pain, disabilityand but joint position sense may take longer duration to showsignificant differences.

References

1. Lennart TH Jacobsson; Definitions of osteoarthritis in theknee and hand. Ann Rheum Dis.1996,55(9):656-8.

2. E M Badley and A Tennant: Changing profile of jointdisorders with age: findings from a postal survey of thepopulation of Calderdale, West Yorkshire, United Kingdom.Ann Rheum Dis. 1992 March; 51(3): 366–371.

3. Felson T.D., Zhang Y; Osteoarthritis: New Insight Part I:TheDisease and its risk factors. Ann. ofInter.Med.2000,133:635-646

4. Leon Sokoloff; Some highlights in the emergence of modernconcepts of osteoarthritis Seminars in Arthritis andRheumatism Volume 31, Issue 2, October 2001, Pages71-107

5. Slemenda C, Heilman DK; Reduced quadriceps strengthrelative to body weight: a risk factor for knee osteoarthritisin women? Arthritis Rheum. 1998 Nov; 41(11):1951-9.

6. Charles Slemenda, Dr. PH; Kenneth D. Brandt, et al,Quadriceps Weakness and Osteoarthritis of the Knee, AnnIntern Med. 1997; 127:97-104.

7. Fischer N. M. ; Gresham G. E. Quantitative effects ofphysical therapy on muscular and functional performancein subjects with osteoarthritis of the knees Archives ofphysical medicine and rehabilitation 1993, vol. 74, pp. 840-84

8. Ufuk Sekir and Hakan Gür Amulti-station proprioceptiveexercise program in patients with bilateral kneeosteoarthosis; functional capacity, pain and sensorimotorfunction. A Randomized Controlled Trial. Journal of SportsScience and Medicine (2005) 4, 590-603

9. David T. Felson, MD, MPH, K Douglas Gross, PT, ScD Theeffects of impaired joint position sense on the developmentand progression of pain and structural damage in kneeosteoarthritis Arthritis Rheum. Author manuscript; availablein PMC 2009 October 6.

10. Da-Hon Lin, Chien-Ho Janice Lin, Efficacy of 2 Non–Weight-Bearing Interventions, Proprioception TrainingVersus Strength Training, for Patients With KneeOsteoarthritis: A Randomized Clinical Trial J Orthop SportsPhys Ther 2009;39(6):450-457

11. Gupta Abhishek Rajendra, Jeba Chitra, Khatri Subhash: Arandomized controlled trial to study the effectiveness ofproprioceptive exercises in osteoarthritis knee: The journalof Indian Association of Physiotherapists,2007: Vol-3;2: Oct:47-52

12. Gail D Deyle et al Physical Therapy Treatment Effectivenessfor Osteoarthritis of the Knee: A Randomized Comparisonof Supervised Clinical Exercise and Manual TherapyProcedures Versus a Home Exercise Program physicaltherapy Vol. 85, No. 12,2005, December, pp. 1301-1317

13. Scott M. Lephart, Freddie H. FU, Proprioception andneuromuscular control in joint stability 2000, Pg349-59.

14. Fitzgerald GK, Childs JD, Ridge TM, Agility and perturbationtraining for a physically active individual with kneeosteoarthritis. Phys Ther. 2002 Apr; 82(4):372-82.

15. Robert Topp, Woolley S, et al, The effect of dynamic versusisometric resistance training on pain and functioning amongadults with osteoarthritis of the kneeArch.Phys.Med.Rehab,2002,Volume 83, Issue 9, Pages1187-1195

16. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, StittLW, Validation study of WOMAC: a health status instrumentfor measuring clinically important patient relevant outcomesto anti-rheumatic drug therapy in patients with osteoarthritisof the hip or knee. J Rheumatoy.1988, Dec; 15(12):33-40.

17. Ray Marks; Peripheral articular mechanisms in painproduction in osteoarthritis, Australian Journal ofPhysiotherapy1992, 38; 289-298.1.


6

Cervicogenic Dizziness: Implications for Physical TherapyAmer A AlSaif1, Eric G Johnson2

1PhD Candidate, 2Professor, Loma Linda University, Department of Physical Therapy, Loma Linda California, USA

Abstract

Cervicogenic Dizziness (CGD) is a relatively new, emergingarea in the medical literature and physical therapy practice.Approximately 60% of patients with whiplash-associated disorderexperience dizziness due to impaired neck proprioceptive input.Patients with CGD typically describe their dizziness as vertigo,lightheadedness, blurry vision, disequilibrium, and/or nausea.Physical therapy interventions for CGD include orthopedic andvestibular rehabilitation strategies. The purpose of this paper isto discuss the etiology of cervicogenic dizziness, describe theproposed pathophysiology, and introduce the physical therapyexamination and intervention process for patients with CGD.

Key Words

Cervicogenic Dizziness, Cervical Vertigo, WhiplashAssociated Disorder, Orthopedic Manual Physical Therapy,Physical Therapy.

Introduction

Balance is maintained through a complex interactionbetween the visual, vestibular, and somatosensory systems.1,2

Multimodal sensory integration occurs in the central nervoussystem where motor responses are generated to coordinatehead and body orientation, postural stability, and gaze stabilityduring head movements.1 When normal sensory integration isimpaired, imbalance and dizziness often occur.1-4 Dizziness isone of the most common medical problems in many countries,including Asia and the United States, especially in the elderlypopulation.5,6 Dizziness is a nonspecific symptomatic descriptionresulting from numerous pathologies including viral or bacterialinfection, head trauma, neurological disease, psychologicalconditions, orthostatic hypotension, migraine and/or headachedisorders, pharmacology, vertebrobasilar insufficiency, andvestibular disorders.1,2,7 Dizziness can also be caused byorthopedic impairments affecting the cervical spine and, in suchcases, is referred to as “cervicogenic dizziness.”1,7 Cervicogenicdizziness has been defined as “a non-specific sensation ofaltered orientation in space and disequilibrium originating fromabnormal afferent activity from the neck.”7 It is different fromvestibular-driven dizziness in that symptoms are usually not asintense and it rarely includes vertigo.7 It is an emerging area ofclinical practice with a growing body of evidence that supportsthe pathophysiology and physical therapy management ofpatients with cervicogenic dizziness. Therefore, the purpose ofthis paper is to provide a brief overview of the theory and clinicalapplication of managing patients with cervicogenic dizziness.

Etiology of Cervicogenic Dizziness

There are several proposed mechanisms leading tocervicogenic dizziness including mechanical compression of thevertebral artery system, irritation of the cervical sympatheticnervous system, and abnormal proprioceptive input from theupper cervical spine.1,2,7-9

Mechanical compression of the vertebral artery system canproduce vertebrobasilar insufficiency (VBI).8,9 The vertebralarteries are branches of the subclavian arteries arising from the

aortic arch.9 The vertebral arteries travel superiorly through C6-C1 transverse foramen, migrate horizontally around the posteriorarch of the atlas, enter the foramen magnum, and merge withone another to form the basilar artery.8,9 The vertebral arteriesencounter several soft tissue and bony structures capable ofproducing mechanical compromise.9 Muscle tightness in theupper cervical spine can potentially occlude the vertebral arteriesreducing brainstem perfusion and causing VBI.7,9,10 In particular,the vertebral arteries travel between the anterior scalene andlongus colli muscles as well as under the inferior capitis obliqueand intertransversarius muscles.7 Cervical spine osteophytesand forward head posture are also potential contributors tovertebral artery compression and VBI.9,10 (Figure 1).

Irritation of the cervical sympathetic ganglia has also beentheorized to contribute to cervicogenic dizziness.1,13 The cervicalganglia are paravertebral ganglia of the sympathetic nervoussystem and travel adjacent to the arterial network and cervicalmusculature antero-lateral along the vertebral bodies.12,13 Thecervical sympathetic ganglia consist of the superior, middle, andInferior cervical ganglion. The superior cervical sympatheticganglion (SCG) is the largest and is located at the level of thesecond and third cervical vertebrae.1,12,13 The SCG is posteriorto the internal carotid artery and internal jugular vein, and anteriorto the longus capitis muscle.12,13 Upper cervical spine muscletightness, bony anomalies, and/or poor cervical spine posturecan potentially compromise this ganglion, leading tohypoperfusion of the vertebral and carotid arterial networkcausing dizziness consistent with cervicogenic dizziness.1,12,13

Abnormal proprioceptive input from the upper cervical spinealso contributes to dizziness. The somatosensory system detectsperipheral stimuli from sensory receptors, includingmechanoreceptors located in human skin.1,2 Mechanoreceptors(Pacinian corpuscles, Meissner’s corpuscles, Merkel’s discs, andRuffini corpuscles) mediate peripheral stimuli including pressure,touch, pain, temperature, and proprioception.1,2,14-16 There arean abundance of mechanoreceptors in the upper cervical spinethat primarily transmit impulses through nerve cells originatingfrom C2 dorsal root ganglion.2,16,17 The mechanoreceptor inputfrom the upper cervical segments (Occiput-Atlas, Atlas-Axis,Axis-C3), particularly from the upper cervical spine muscles,report directly to the vestibular nuclear complex and the superiorcolliculus.1,2,17 The upper cervical spine mechanoreceptors alsoconverge in the central cervical nucleus (CCN), which servesas a pathway to the cerebellum for integrating and organizingvestibular, ocular, and proprioceptive sensory input.2,13,16,17 TheCCN also sends coordinated information to the cortex formaintenance of postural equilibrium and body orientation (Figure2).1,2,17,18 Cervical spine reflexes contribute to head orientation,eye movement control, and postural stability; cervical collic reflex,the cervical ocular reflex, and cervical spinal reflex, respectively(Figure 3).1,2 These cervical reflexes work in conjunction withvestibular collic reflex, vestibular ocular reflex, and the vestibularspinal reflex.1,2,17,19 Abnormal sensory input from the vestibularand upper cervical spine can lead to dizziness, unsteadiness,and visual disturbance.1,2,13,17,19

Cervical Spine Trauma

Abnormal cervical somatosensory input can altersomatosensory control and negatively impact postural stability

Amer A AlSaif / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

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Fig. 1: Vertebrobasilar Arterial System. (Permission granted from NeuroScience Online Section II: Sensory Systems).11

and vision.1 Cervical spine trauma, such as whiplash-associateddisorder (WAD), can impair cervical somatosensory function bycausing ischemia, inflammation, and stress.1 Moreover, evidencesuggests that direct trauma to the neck can lead to cervical spinemuscle fatigue that ultimately modifies the discharge firing rateof sensory receptors, thus affecting joint position of the headand neck as well as postural stability.3,20-22,24-27 Deficits inoculomotor function have also been described in the literaturein patients with WAD.1,28 Tjell and Rosenhall28 reported abnormalsmooth-pursuit eye movements when the neck was rotatedunder a stable head in WAD patients. Additionally, greater lossof eye motor control was identified among WAD patientscomplaining of dizziness.1,28 Problems of convergence anddiplopia have also been associated with WAD patients.1 It isestimated that approximately 60% of all WAD patients developdizziness.1

Physical Therapy Evaluation

The physical therapy evaluation includes subjective andobjective components. Because CGD is one of numerous typesof dizziness, the evaluation strategy can be challenging.1,7

According to Wrisley et al, CGD is a diagnosis of exclusion,meaning that competing causes of dizziness must be ruled out.7

Physical therapists need to carefully review the past medicalhistory and ask specific questions about the patient’s dizzinessin order to determine that the dizziness is cervicogenic.7 Episodicdizziness lasting minutes to hours is a common complaint in

patients with CGD.7 They may also report a general sense ofdisequilibrium or lightheadedness as well as visual disturbances.Vertigo is rarely a chief complaint in CGD patients.1,7

Circumstances that frequently produce their dizziness includeneck pain.1,7 An example of a CGD Physical Therapy SubjectiveExamination Form is provided in Table 1.

The physical examination for CGD patients includes amedical screening component that is performed first (Table 1).1,7

The medical screening component includes three differentphases: screening of the (1) cervical spine stability, (2) cervicalvascular system, and (3) central nervous system. If any of thesemedical screening tests produce positive or abnormal results,the physical therapist must refer the patient to a physician forfurther medical consultation. Otherwise, the physical therapistcontinues with the physical examination. The vestibular systemis examined to determine whether the dizziness is being causedby the peripheral or central vestibular system.7 If the peripheralvestibular system examination is positive, appropriate vestibularrehabilitation interventions are implemented. If the centralvestibular examination is positive, the physical therapist shouldrefer the patient to a physician for further medical consultation.Otherwise, the physical therapist continues the physicalexamination.7

The following tests may help determine whether thedizziness is being caused by the neck. The neck torsionnystagmus test (NTNT) is performed by stabilizing the patient’shead and rotating his or her body underneath (Figure 4).28 TheNTNT is positive if nystagmus is elicited. The neck torsion


8

Fig. 2: Important neurological pathways between the upper cervical spine and the central nervous system concerning head andbody orientation as well as head-eye coordination. Postural balance and visual stability is dependent upon healthy neuralcommunication.

Figure 3. Cooperative reflexes between the vestibular system and the upper cervical spine. These reflexes are dependent uponhealthy integrative central nervous system communication, particularly with the vestibular nuclear complex, in order to maintainnormal postural balance and visual stability.

smooth pursuit (NTSPT) is performed by observing ocularsmooth pursuit with the patient’s head in neutral followed byneck rotation under a stable head. A positive NTSPT resultswhen smooth pursuit is normal in the neutral position andabnormal when the neck is in the rotated position.1,28 The jointposition error (JPE) test examines cervical spine proprioception.The JPE is performed by asking the patient to sit 90 cm awayfrom a fixed target while wearing a head strap with a laser pointer,as shown in (Figure 5).22,23 The physical therapist asks the patientto look straight ahead at the center of the fixed target. This isthe starting position.23 The physical therapist then asks the patientto close their eyes, rotate their neck as far as they can, andreturn their head to the starting position with as much precisionas possible.23 A normal JPE requires the patient to be within 4.5

degrees of the starting position. 23 The manual traction test (MTT)is performed while the patient is seated (Figure 6).1 The test isconsidered positive if the compression increases or producesdizziness and traction relieves it.1

Physical Therapy Intervention

Physical therapy intervention has been shown to beeffective in reducing CGD symptoms. According to Wrisley etal7, CGD symptoms typically increase with neck pain. Therefore,treating neck pain among this group of patients is one of themain objectives for physical therapists. Intervention strategiesmay include: (1) orthopedic manual techniques specific to thecervical spine region, (2) head and neck proprioceptive


9

Fig. 4: Neck Torsion Nystagmus Test

Figure 5: Joint Position Error Test

Figure. 6: Manual Traction Test

rehabilitation program, and (3) cervical-ocular motor exercises.Cervical spine pain and inflammation can be treated with a

variety of physical therapy modalities, including cryotherapy,thermotherapy, ultrasound, and cervical spine traction.1,7 Cervicalspine hypomobility is common among CGD patients and mayincrease symptoms of dizziness.1,7 However, cervicalhypomobility can be treated with joint specific mobilizationtechniques and tissue/age-specific stretching programs.1,7

Cervical spine proprioception impairments can be treatedwith a specific proprioceptive rehabilitation program. Theproprioception program includes slow, passive head movementswith fixed-target gaze exercises (the clinician passively movesthe patient’s head while the patient maintains a fixed gaze on a

stationary target).22,23 The program can be progressed by doingactive head movements rather than passive head movements.Also, the clinician may progress the program by instructing thepatient to perform active head movements while maintainingtheir gaze on a fixed target with their trunk passively or activelymoved.23 Another way of performing the program is to instructthe patient to close their eyes and actively rotate their head,return to the starting position, and open their eyes.23 If the patientcannot see the target, they can keep their eyes open andcontinue rotating their head until they can see the target.22,23

This training provides the patient with information about cervicalspine joint position sense and can be performed with restrictedperipheral vision using foveal glasses.1,7,22,23 Input from cervicalspine afferent nerves can alter the function of the oculomotorsystem.1,7,23 Thus, oculomotor training is important to reducepotential extraocular muscle weakness.28 Extraocular motorfunction can be managed using smooth-pursuit (patient keepshead still while eyes follow a moving target), saccades (patientkeeps head still and quickly moves eyes between targets), X1adaptation exercises (patient moves head from side to side whilemaintaining the gaze on a stationary target), and X2 adaptationexercises (patient moves head and a hand-held target inopposite directions while maintaining gaze on moving target atall times).1,22,28 All extraocular exercises can be progressed byincreasing the speed of movement, range, duration, andfrequency. Also, the exercises could be progressed by graduallydecreasing the stability of support and changing from static todynamic positions.1,22,28

Conclusion

Cervicogenic dizziness is often the result of a sensorymismatch between the vestibular, somatosensory, and visualafferent inputs. Physical trauma involving the cervical spine, suchas whiplash injury, is a common mechanism of injury in CGDpatients. Physical trauma contributes to impairment in the uppercervical spine proprioceptive input leading to symptoms includingdisequilibrium and dizziness. In order to determine the origin ofthe patient’s dizziness, the physical therapist must exclude allcompeting causes of dizziness. Once CGD has been confirmed,appropriate interventions are implemented to reduce cervicalspine pain and inflammation, improve cervical spineproprioception, improve cervico-ocular function, and restore jointand soft tissue range of motion and mobility.


10

Physical Therapy Dizziness Examination Form

Patient: Date: Date of Birth:Referral Source: Diagnosis: Occupation:

SUBJECTIVE EXAMINATION1. Chief complaint and date of onset:2. Mechanism of injury:3. Tempo of symptoms: constant/episodic seconds/episodic minutes/episodic hours4. Do you experience spells of vertigo? YES NO mVAS range _____/10; currently _____/105. Do you experience disequilibrium? YES NO mVAS range _____/10; currently _____/106. Do you experience lightheadedness? YES NO mVAS range _____/10; currently _____/107. Do you experience oscillopsia? YES NO mVAS range _____/10; currently _____/108. Circumstances that exacerbate/produce symptoms:9. Fall History:10. Past Medical History:11. Medications:12. Do you have steps in your home? YES NO13. Do you smoke/drink, and if so, how much? YES NO14. Do you have trouble sleeping? YES NO15. Was previous functional level normal? YES NO

ORTHOPEDIC ASSESSMENT1. Cervical Spine Stability: Alar Ligament/Sharp-Purser/Lateral Shear + OR -2. Positional Tolerance Testing: + OR –3. Cervicogenic Dizziness Testing: NTNT/NTSPT/NPPT/MTT/JPE _____ cm difference + OR -4. Cervical Spine AROM/PROM:

NEUROLOGICAL ASSESSMENT5. Proprioception: + OR -6. CNS Testing: Babinski/Clonus/DTR/RAM/Finger to Nose EO and EC + OR –

VESTIBULAR ASSESSMENT7. Central Vestibular Testing: Ocular Alignment / Spontaneous Nystagmus / Gaze Evoked Nystagmus

Smooth Pursuit / Saccadic Eye Movement / VOR Cancellation Test

8. Peripheral Vestibular Testing: Hallpike Dix Test / Roll Test / Head Thrust Test/ Dynamic Visual AcuityHead – Shaking Nystagmus Test

BALANCE TESTS:9. Balance Testing: Romberg/Sharpened Romberg/Timed Up and Go/Functional Reach Test + OR –10. Berg Balance Scale: _____/56; Dynamic Gait Index: _____/24

DIZZINESS INVENTORY:16. DHI Score: _____/100; ABC Score: _____/100

TREATMENT PLAN:

RECOMMENDATION TREATMENT PLAN: ____________ DAYS/WK FOR _______WKS.

Table 1: Physical Therapy Cervicogenic Dizziness Examination Form

Acknowledgements

The authors thank the Physical Therapy Departments atKing Abdulaziz University and Loma Linda University forsupporting this writing effort.

Intrest of Conflict

Not identified.

References

1. Jull G, Sterling DF, Treleaven, O’Leary S. Whiplash,Headache, and Neck Pain: Research-Based Directions forPhysical Therapies. 1 ed. Edinburgh: Churchill Livingstone;2008.

2. Kristjansson E, Treleaven J. Sensorimotor function and

dizziness in neck pain: implications for assessment andmanagement. J Orthop Sports Phys Ther 2009;39:364-377.

3. Kogler A, Lindfors J, Odkvist LM, Ledin T. Postural stabilityusing different neck positions in normal subjects andpatients with neck trauma. Acta Otolaryngol 2000; 120: 151-155.

4. Baccini M, Risaliti I, Rinaldi LA, Paci M. Head position andneck muscle fatigue: Effects on postural stability. Gait &Posture 2006;24S: S9-S10.

5. Yin M, Ishikawa I, Wong WH, Shibata Y. A clinicalepidemiological study in 2169 patients with vertigo. AurusNasus Larynx. 2009;36:30-35.

6. Von Brevern M, Radtke A, Lezius F, Feldmenn M, Ziese T,Lempert T, Neuhauser H. Epidemiology of benignparoxysmal positional vertigo: a population based study. JNeurol Neurosurg Psych. 2007;78:710-715.

7. Wrisley DM, Sparto PJ, Whitney SL, Furman JM.


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Cervicogenic dizziness: a review of diagnosis andtreatment. J Orthop Sports Phys Ther 2000;30:755-766.

8. Johnson EG, Landel R, Kusunose RS, Appel TD. Positivepatient outcome after manual cervical spine managementdespite a positive vertebral artery test. Manual Therapy.2008;13:367–371.

9. Johnson EG. Vertebral Artery Testing in Dizzy Patients: Areview of the literature and clinical considerations. InColumbus F, (Ed.). Dizziness: Vertigo, Disequilibrium andLightheadedness. In Press. Hauppauge, NY: Nova SciencePublishers. 2008.

10. Johnson EG, Cordett TK. A different spin on the vertebralartery test for examining dizzy patients. International Journalof Medical and Biological Frontiers. 2011; In Press.

11. NeuroScience Online. Section II: Sensory Systems.Available at http://neuroscience. uth.tmc.edu/s2/ii1-3.html.Accessed May 18, 2009. Permission granted.

12. Clemente CD, ed. Anatomy of the Human Body. 13thAmerican ed. Baltimore, MD: Williams & Wilkins, 1984.

13. Schenk R, Coons LB, Bennett SE. Cervicogenic dizziness:a case report illustrating orthopaedic manual and vestibularphysical therapy comanagement. J Man Manip Ther.2006;14(3):E56- E68.

14. Hellstrom F, Roatta S, Thurnbeerg J, et al. Responses ofmuscle spindles in feline dorsal neck muscles to electricalstimulation of the cervical sympathetic nerve. Exp BrainRes 2005;165:328-342.

15. Herdman S, Schubert MC. Vestibular rehabilitation. In:O’Sullivan SB, Schmitz TJ, eds. Physical Rehabilitation:Assessment and Treatment. 4th ed. Philadelphia, PA: FADavis Company, 2000:821-843.

16. Guyton AC. Textbook of Medical Physiology. 8th ed.Philadelphia, PA: W.B. Saunders Company; 1991:67-79.

17. Dutia MB. The muscles and joints of the neck: theirspecialization and role in head movement. Prog Neurobiol.1991;37:165-178.

18. Jull G, Falla D, Treleavan J, Sterling M, O’Leary S. A

therapeutic exercise approach for cervical disorders. In:Boyling JD, Jull G, eds. Grieve’s Modern Manual Therapy.The Vertebral Column. Edinburgh, UK: ChurchillLivingstone; 2004: 451-461.

19. Corneil BD, Olivier E, Munoz DP. Neck muscle responsesto stimulation of monkey superior colliculus. I. Topographyand manipulation of stimulation parameters. J Neurophysiol.2002;88:1980-1999.

20. Revel M, Andre-Deshays C, Minguet M. Cervicocephalickinesthetic sensibility in patients with cervical pain. ArchPhys Med Rehabil. 1991;72:288-291.

21. Heikkila H, Astrom PG. Cervicocephalic kinestheticsensibility in patients with whiplash injury. Scand J RehabilMed. 1996;28:133-138.

22. Heikkila HV, Wenngren BI. Cervicocephalic kinestheticsensibility, active range of cervical motion, and oculomotorfunction in patients with whiplash injury. Arch Phys MedRehabil. 1998;79:1089-1094.

23. Revel M, Minguet M, Gregoy P, Vaillant J, Manuel JL.Changes in cervicocephalic kinesthesia after aproprioceptive rehabilitation program in patients with neckpain: a randomized controlled study. Arch Phys MedRehabil. 1994;75:895-899.

24. Stapley PJ, Beretta MV, Dalla Toffola E, Schieppati M. Neckmuscle fatigue and postural control in patients with whiplashinjury. Clin Neurophysiol. 2006;117:610-622.

25. Gosselin G, Rassoulian H, Brown I. Effects of neck extensormuscles fatigue on balance. Clin Biomech. 2004;19:473-479.

26. Schieppati M, Nardone A, Schmid M. Neck muscle fatigueaffects postural control in man. Neuroscience.2003;121:277-285.

27. Pinsault N, Vuillerme N. Degradation of cervical jointposition sense following muscular fatigue in humans. Spine.2010;35:294-297.

28. Tjell C, Rosenhall U. Smooth pursuit neck torsion test: aspecific test for cervical dizziness. Am J Otol. 1998;19:76-81.


12

Randomised Controlled Study of Mulligan’s Vs. Maitland’sMobilization Technique in Adhesive Capsulitis of Shoulder JointAnkit Shrivastava1, Ashok K Shyam2, Shaila Sabnis1, Parag Sancheti2

1Sancheti Institute, College of Physiotherapy, 16, Shivaji nagar, Pune, Maharashtra, India, 2Sancheti Institute of Orthopaedic andRehabilitation, Shivaji nagar, Pune, Maharashtra, India, Indian Orthopaedic Research Group, Thane, Maharashtra, India

Abstract

Introduction

Physical therapy is the most important part of conservativetreatment of frozen shoulder. Both Maitland and Mulligan’stechniques have been found effective. We here did acomparative study to find the effectiveness of both thesetechniques in frozen shoulder rehabilitation

Material and methods

A prospective randomized double blind study wasperformed with 20 patients in each treatment arm. In Maitlandgroup mean age was 59.2 (±7.18) years (7 males and 13females) and in the Mulligan group the average age was 51.15(±8.53) years (12 males and 8 females). We compared the twogroups with respect to pain VAS, shoulder range of motion andShoulder Pain and Disability Index (SPADI) score.

Results

All the parameters, pain VAS, SPADI score and shoulderrange of motion improved significantly for the entire group. InMaitland group, pain improved from 7.35 to 4.05, SPADIimproved from 52 to 40 and all range of motion except extensionand internal rotation were significantly improved (p<0.05). InMulligan’s group, pain improved from 5.85 to 3.6, SPADIimproved from 52 to 42 and all ranges except internal rotationimproved significantly.

Discussion

Both the treatment techniques i.e. Maitland and Mulliganare improve the pain VAS score, but response to Mulligan’s wasbetter. Mulligan mobilization technique is better than Maitlandin terms of improvement in the range of extension whileremaining ranges were similarly improved by both techniques.Studies of larger sample size, with a longer intervention periodare needed to confirm our findings

Introduction

Adhesive capsulitis (frozen shoulder) is a condition ofuncertain etiology characterized by pain and progressive lossof both active and passive shoulder motion.1 Various method oftreatment are available for adhesive capsulitis which includes:heating2,3,4 stretching exercises by physiotherapist or auto-stretching by patients4,5,6,7,8,9 and scapular setting5 exercisesalong with the pendulum exercises4,6,13 which helps in maintainingand improving strength of shoulder girdle muscles and improvefunction2. Joint mobilization is the treatment of choice to restoreand improve synovial shoulder joint mobility 4,5,6,13. Variousschools of manual therapy have been advocated for thetreatment of frozen shoulder5,6,8. Various grades of mobilizationssuch as mid range and end range mobilizations are suggestedby Maitland and Kaltenborn to improve joint mobility and reducepain 5,16,11, 12,16

Nicholson10 compared pain and range of movement of theshoulder joint in two groups who received mobilization alongwith exercises and the other group treated with active exercisesonly and that the found mobilization group had lesser pain andjoint stiffness than control group. Other researchers have alsofound Maitland’s mobilization to be effective in this condition4,5,6,9,11,12,13,14, though different authors have used different gradesand names of mobilizations. On the other hand another studyby Bulgen et al15 found no place for Maitland mobilization oversteroid injection or no treatment. This is believed that gradedmobilization stretches the tightened capsule and otherperiarticular soft tissues5,11,12,13,14,17. Direction of glides dependson the range to be aimed at. The choice of direction followsconvex-concave rule12,18. Johnson et al found posterior glide tobe better than anterior glide to improve glenohumeral abduction18.

Similarly Mulligan’s mobilization with movement (MWM)have shown convincing results in improving pain and mobility ofdifferent joints in which it was administered4,5,19-24. Mulliganproposes that the MWM technique has its effect by correctingthe positional faults in the joints that occur following injuries orstrains 21,24. MWM is the simultaneous application of thecorrective glide to the joint along with active movement by thepatient. In the end range passive over-pressure is applied bypatient or assistant 21,24,25. MWM when used for shoulders withlimited range of motion because of pain had shown improvementin range of motion and pressure pain threshold22. Even if MWMis applied to the elbow for lateral epicondylgia, it has improvedshoulder external rotation 23. The author attributes this changeto the neurophysiological activities which helps to move shoulderthrough a wider range of motion. In a systemic review of thestudies on MWM, the results were inconclusive19.

In the literature review, we found only a single study whichcompares both Maitland’s and Mulligan’s mobilization techniqueson adhesive capsulitis of the shoulder and it shows that boththe techniques are effective in treating the condition, with MWMalso additionally improving the motor strategies of thescapulohumeral rhythm5. Whereas, a Cochrane review forshoulder pain found no benefit of any particular physiotherapytechnique over other26. Therefore the present study intend tocompare the efficacy of the two mobilization techniques i.e.Maitland’s grades oscillation and Mulligan’s mobilization withmovement, in adhesive capsulitis of the shoulder joint.

Materials and Methodology

A prospective randomized double blind study wasperformed at Sancheti Institute for Orthopedic and Rehabilitation,Pune between 2006- 2008. We included both male and femalesubjects with second stage of adhesive capsulitis with bothprimary and secondary cause who were showing capsularpattern 2,8. Exclusion criteria were prior shoulder surgery,shoulder arthritis, painful shoulder, severe systemic illness andpatients on regular analgesics. Breakthrough analgesicconsumption by patients was allowed in our study. Thepermission to carry out the study was obtained from theconcerned authority / ethical committee. A prior written consentwas taken from each subject. Double blinding was done withthe assessment therapist and the patient both being blindedwith respect to treatment protocol followed. Fifty four subjects

Ankit Shrivastava / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

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of second stage adhesive capsulitis were screened and 40 wereselected according to inclusion criteria. Subjects were randomlyallotted to the two groups, Maitland group and Mulligan groupby computerised random sequence generator. There were 7males and 13 females in the Maitland group and 12 males and8 females in the Mulligan group with average age of 59.2 (±7.18)years in the Maitland group and 51.15 (±8.53) years in theMulligan group. A pre-intervention assessment was carried outby the assessment therapist on first day when the patient enrolledfor the study. Outcome measures were Pain (on Visual AnalogueScale (VAS), score out of 10 on a 100 mm horizontal line),shoulder ROM (in degrees with Universal 360 goniometer) testedfor reliability – Riddle et al (1987) [27] and Shoulder Pain AndDisability Index (SPADI), a functional scale for shoulder. Theintervention common to both groups included hot fomentationfor 10 minutes, Codman pendulum exercises, scapular settingexercises, finger ladder, wand exercises and stretching of thetightened muscles of the shoulder girdle. Frequency of treatmentfor both the groups was six times a week for two/four weeks.The Maitland group receives grades oscillation technique andthe Mulligan group were treated with mobilization withmovement.

Technique

Maitland’s Graded Oscillations Technique: Grade of glidewas decided during the treatment depending on patientssymptoms, grade I and II for relieving pain in loose pack positionand spasm and grade III and IV in close position for stretchingand improving the range. Individual glides are explained asfollows:

Posterior Glide

With patient in supine position, therapist holds his/her armproximally and applying a distraction force, glides the humeralhead posteriorly.

Inferior Glide

The patient lays supine, therapist stands at the head endof the patient facing his/her feet. Holding the proximal arm ofthe patient, therapist gives a distraction force to the glenohumeraljoint and glides the humeral head inferiorly.

Anterior Glide

Patient is positioned prone and the therapist holds the distalarm, above the epicondyles with one hand for distraction andwith other hand therapist applies anterior glide to the humeralhead.

Mulligan’s Mobilization with Movement: While applying thetechnique the range should increase without any pain. Passiveoverpressure is applied in the end of range and three sets often repetitions are given for each mobilization.

Flexion and Abduction

Patient sitting with therapist posterolateral to him/her.Therapist places the Mulligan belt across the humeral head andto his waist. Leaning backward, he applies a posterolateral glideto the shoulder joint and then asks the patient to perform thepainful/restricted movement of shoulder flexion or abduction,which would be pain free now.

Internal Rotation

Patient sitting or standing with therapist by his/her side.Therapist applies an inferior glide to the humerus head with thepatient’s shoulder in available degree of abduction. With the

glide maintained the patient actively rotates the shoulderinternally without any pain now.

External Rotation

The patient lies supine with his/her shoulder horizontallyflexed till 900. Therapist places the belt at the humeral head,applying a lateral distraction to the joint the patient was askedto rotate the shoulder externally.

A post-intervention assessment was done, after 4 weeksof intervention, by the assessment therapist for pain, shoulderROM measurements and SPADI. Final readings were noted inthe assessment form, master chart was prepared and data wasanalysed. We compared the two groups with respect topreintervention factors like VAS score, shoulder ROM and SPADIscore and post intervention factors like VAS score, ROM andSPADI score.


The statistical analysis was done with level of significanceset at p < 0.05 for the analysis with appropriate Bonferreni’scorrection. Within Group Analysis of VAS, SPADI and Range ofmotion was done using repeated measures ANOVA for both thegroup. Analysis of VAS between the groups was done usingMann-Whitney U test. Analysis of SPADI and Range of motionbetween both the groups was done using unpaired t test.

Results

The study included 40 subjects, 19 males and 21 femaleswith a mean age of 54.93±9.06 with complaints of shoulder pain(mean VAS=6.5±1.7) and restriction of shoulder range of motion,with or without diabetes. Table 1 gives the demographicdifferences between the groups.

PARAMETERS MAITLAND MULLIGANAge 59.2 51.15Gender (M:F) 7:13 12:8Pain (VAS) 7.35 5.85SPADI 52 52Flexion 103.5 104.5Extension 33.75 35.25Abduction 77.75 79.5Internal Rotation 42 40.5External Rotation 22.5 22.75

Table 1: Various pre intervention parameters in both the groups

MAITLAND MULLIGANPARAMETERS Pre Post p- Pre Post p-

value valuePain (VAS) 7.35 4.05 0.000 5.85 3.6 0.000SPADI 52 40 0.001 52 42 0.025Flexion 103.5 121.25 0.000 104.5 122 0.000Extension 33.75 38 0.171 35.25 41 0.003Abduction 77.75 91.25 0.000 79.5 99.5 0.001Internal 42 46.5 0.281 40.5 41.25 1RotationExternal 22.5 39.75 0.000 22.75 33.5 0.000Rotation

Table 2: Within group analyses of outcome variables in boththe groups

In the Maitland group all the variables except the degree ofextension and internal rotation improved post intervention [table2]. In the Mulligan group all except internal rotation improved[table3]. Thus the Mulligan group seems to significantly improveupon the preoperative extension as compared to the Maitlandgroup, however most of the variables improved in both thegroups.


14

Table 3: Comparative analyses of outcome variables betweenthe two groups.

PARAMETERS MAITLAND MULLIGAN p-value

Pain (VAS) 4.05 3.6 <0.05SPADI 40 42 0.686Flexion 121.25 122 0.628Extension 38 41 0.319Abduction 91.25 99.5 0.42Internal Rotation 46.5 41.25 0.155External Rotation 39.75 33.5 0.02

Comparison between the post intervention values betweenthe two groups is given in table 3. Mulligan group had betterpain score but the external rotation was better in the Maitlandgroup. Rest of the variables were comparable between the twogroups.

We had no technique related complication in both thegroups and no patient dropped out of the study due to problemsin therapy.

Discussion

The present study was undertaken to evaluate efficacy ofthe two manual therapy techniques, i.e. Mulligan (MWM) andMaitland mobilization technique on the adhesive capsulitis ofthe shoulder joint, and also to compare which of the techniquesis better in terms of reducing pain, improving functional score(SPADI) and the joint mobility.

The intervention was given for a period of 2 weeks, followingwhich the mobilizations were discontinued and patients wereput on a home exercise programme for 2 weeks which wascommon to both the groups. The effect of both the treatmenttechniques on pain was positive i.e. they both were effective inrelieving the patients’ pain with 2 weeks intervention. When theresponses were compared between the groups, the resultshowed significant difference at follow-up, which means thatMaitland is better than Mulligan in relieving the pain. Results ofthe present study are in accordance with the previous reports.36

The study done by Ryans et al showed significant improvementin the outcome measures in the group treated by physiotherapywhich included Maitland’s mobilization. A similar study done tocompare the effectiveness of two of the Maitland’s mobilizationtechniques (high grade and low grade) found that the relief issimilar in both of the mobilization techniques.37 In the presentstudy, both Low Grade and High Grade Mobilization techniquewere used (grade II, III and IV). In one study which comparedthe effects of three of the mobilization techniques i.e. end rangemobilization (ERM), mid range mobilization (MRM) and MWM,the results showed that ERM and MWM is better than MRM inimproving the range of motion of the shoulder joint, pain andfunctional ability, although MRM was also effective in improvingthe pain, range and the functional ability of the subjects. Thusthe results show that both the type of mobilization techniques(Maitland and Mulligan) is effective in the treatment of frozenshoulder. The result also showed that there is improvement inthe scapulohumeral rhythm with 3 weeks of MWM.18 Teys et alfound that MWM technique is effective for immediate pain reliefand improve ROM of shoulder.40 Thus supporting the results ofthe present study.

In contrast to the findings of the present study, in the studydone by Ginn et. al. in 1997 showed no significant difference inthe response to pain in the treatment (physiotherapy includingMaitland mobilization) and the control group in patients withshoulder pain.29 Green et al in their Cochrane review in 2008concluded that there is little or no benefit of any physiotherapyintervention either alone or in combination on shoulder pain,although the studies included in the review had weakmethodology.7 we can attribute the response to pain in this study

to the neurophysiologic effect of mobilization and also to theapplication of hot fomentation which increases the extensibilityof the soft tissues45 and supervised physiotherapy.

The present study shows there was a significant differencein the SPADI score at follow-up in both the groups. Whereas,between groups comparison shows that the difference was notsignificant between the groups. This signifies that both of theabove mentioned mobilization techniques are equally effectivein improving the functional outcome in the patients. The effectof the techniques on the range of motion is varied in the presentstudy. There is overall improvement in all the ranges with boththe techniques at follow-up visits except the extension andinternal rotation. The reason for this may be due to the non-adherence of the subjects to the home exercise programme,discontinuance from the mobilization and supervisedphysiotherapy.

The improvement in the range of motion was seen in almostall the ranges within both the groups from baseline to follow-up.This pattern was similar in both the groups. In the Maitland group,except the extension and internal rotation, flexion, abductionand external rotation ranges improved post intervention. In theMulligan group, the improvement in the ranges was significantfor flexion, extension, abduction and external rotation. Theimprovement in the Mulligan group, can be attributed to thecorrective glide to achieve optimal alignment of the articularsurfaces and its maintenance by appropriate recruitment of themuscles by patients active efforts. This goes well with theMulligan concept of positional fault. The alteration of the shoulderbiomechanics can be due to capsular tightness seen in AdhesiveCapsulitis. This capsular tightness pulls the head of humerustowards glenoid fossa, thus altering humeral head excursion inthe glenoid. This glenohumeral mechanism alteration leads toaltered mechanics of the scapulothoracic and acromioclavicularjoints which in turn leads positional faults in these joints also.Mobilizations have definite effect on this altered biomechanics.Kalternborn (1989) says that for any normal motion at the jointto occur, proper joint kinetics is necessary. Adequate capsuleextensibility is necessary to allow roll sliding to occur betweenthe body surfaces with in the joint. Any restriction of the jointcapsule or faulty relationship to the joint surface will interferewith normal motion. Normal mobility can be restored by eithergeneral or specific mobilization technique. The biomechanicaleffect manifests itself when forces are directed towardsresistance but within the limits of a subject’s tolerance. Themechanical effect may include the breaking up of adhesion,realigning collagen or increasing fiber glide.46 In a similar studyconducted by Nicholson,48 using grade III and IV of Maitland’sglides, the results showed improvement in pain and passiveshoulder abduction, but the change in rotations were notsignificant. However, the subjects received intervention for thewhole period of 4 weeks, unlike the present study. The resultsare similar to those of the present study.

Joint mobilization techniques are assumed to inducevarious beneficial effects. The neurophysiologic effect is basedon the stimulation of peripheral mechanoreceptors and theinhibition of nociceptors.49 The biomechanical effect manifestsitself when forces are directed toward resistance but within thelimits of a subject’s tolerance. The mechanical changes mayinclude breaking up of adhesions, realigning collagen, orincreasing fiber glide when specific movements stress thespecific parts of the capsular tissue.49 Furthermore, mobilizationtechniques are supposed to increase or maintain joint mobilityby inducing changes in synovial fluid, enhanced exchangebetween synovial fluid and cartilage matrix, and increasedsynovial fluid turnover. In the Maitland classification system, thepassive mobilization approach is not a recipe of specifictechniques but rather a concept of management in whichaccessory and physiologic passive movements of the joint areapplied at various grades of intensity depending on a subject’spain and joint stiffness. A vital component of the Maitland


15

approach is that the treatment is based on constant assessmentand reassessment, with subsequent individual modifications oftreatment techniques. Therefore in the present study also thepatients’ responses to the mobilization were assessed and thegrade of mobilization was decided accordingly. Thus a patientcomplaining of soreness after a treatment session was given alower grade than earlier (grade I or II) in order to relieve theirpain. This can be accounted for better pain response in theMaitland’s group than the Mulligan’s group.

There are several limitations of our study namely, smallsample size, short follow up duration, muscle strength andscapulohumeral rhythm were not considered in outcome

In conclusion, both the treatment techniques i.e. Maitlandand Mulligan are improve the pain VAS score, but response toMulligans is better. Both the techniques are equally effective inimproving the functional score. Mulligan mobilization techniqueis better than Maitland in terms of improvement in the range ofextension while remaining ranges were similarly improved byboth techniques. Studies of larger sample size, with a longerintervention period are needed to confirm our findings

References

1. Myers J.B., Lephart S. M. The Role of the SensorimotorSystem in the Athletic Shoulder. Journal of Athletic Training.2000;35(3):351-363.

2. Schenkman M, De Cartaya VR. Kinesiology of the shouldercomplex. J Orthop Sports PhysTher 1987;8:438-450.

3. Paine RM, Voight ML. The role of the scapula. J OrthopSports PhysTher. 1993;18:386 –391.

4. Levangie PK, Norkins C. Joint Structure and Function. 3rdEdn, Jaypee Pub; 215-216.

5. Oatis CA. Kinesiology- mechanics and pathomechanics ofhuman movement. Lippincott Williams and Wilkins. 132-133

6. Anton HA. Frozen Shoulder. Can Fam Physician 1993;39:1773-1777.

7. Green S, Buchbinder R, Hetrick S. Physiotherapyinterventions for shoulder pain. Cochrane Database SystRev. 2003;(2):CD004258.

8. Ginn KA, Herbert RD, Khouw W, Lee R. A randomized,controlled clinical trial of a treatment for shoulder pain. PhysTher. 1997;77:802-811.

9. Grubbs N. Frozen shoulder: A review of literature. JOSPT1993; 18(3):479–487.

10. Kazemi M. Adhesive capsulitis: a case report, J Can ChiroprAssoc 2000; 44(3) :169–176

11. Asher SN. Frozen shoulder syndrome. Osteopath dec 2000.12. Neviaser Rj, Neviaser TI: The frozen shoulder: Diagnosis

and management. Clin Orthop 223:59-64, 198713. Wadsworth CT: Frozen shoulder. Phys Ther 66: 1878- 1883,

198614. Bunker TD, Anthony PP. The pathology of frozen shoulder-

a dupuytren like disease. J Bone Joint Surg [Br] 1995;77-B:677-83.

15. Uysal FG, Kozanoglu E.Comparision of the early responsesof the two methods of rehabilitation in adhesive capsulitis.Swiss med wkly 2004;134:353–358

16. Smith LL, Burnet SP, McNeil JD. Musculoskeletalmanifestations of diabetes mellitus. Br J Sports Med2003;37:30–35

17. Dias R, Cutts S and Massoud S. Frozen shoulder. BMJ2005;331;1453-1456

18. Yang JI, Chang C, Chen S, et al. Mobilization techniquesin subjects with frozen shoulder syndrome: randomizedmultiple treatment trial. Phys Ther. 2007;87:1307–1315.

19. Mao CY, Jaw WC, Cheng HC. Frozen shoulder: correlationbetween the response to physical therapy and follow-upshoulder arthrography. Arch Phys Med Rehabil 1997;78:857-9.

20. Siegel LB, Cohen NJ, Gall EP. Adhesive capsulitis: a stickyissue. Am Fam Physician 1999; 59:1843–52.

21. Bulgen DY, Binder Al, Hazleman BL, Dutton I, Roberts S:Frozen shoulder: Prospective clinical study with anevaluation of three treatment regimens. Ann Rheum Dis1984, 43:353-360.

22. Maitland GD. Treatment of the glenohumeral joint bypassive movement. Physiotherapy. 1983; 69:3–7.

23. Grubbs N. Frozen shoulder: A review of literature. JOSPT1993; 18(3):479–487.

24. Donatelli R, Greenfield B: Case study: Rehabilitation of astiff and painful shoulder: A biomechanical approach. OrthopSports Phys Ther 1987, 9: 1 18- 126.

25. Kessler RM: The shoulder. In: Kessler RM, Hertling D (eds),Management of Common Musculoskeletal Disorders.Philadelphia: Harper & Row,1983 pp 274-3 10

26. Nicholson CC: The effects of passive joint mobilization onpain and hypomobility associated with adhesive capsulitisof the shoulder. / Orthop Sports Phys Ther 1985 6:238-246.

27. Neviaser Js. Adhesive Capsulitis of The Shoulder: A Studyof the Pathological Findings in Periarthritis of the ShoulderJ Bone Joint Surg Am. 1945;27:211-222.

28. Johnson AJ, Godges JJ, Zimmerman GJ, Ounanian LL;the Effect of Anterior Versus Posterior Glide JointMobilization on External Rotation Range of Motion inPatients with Shoulder Adhesive Capsulitis.J Orthop SportsPhys Ther 2007;37(3):88-99.

29. Vermeulen HM, Rozing PM, Obermann WR, et al.Comparison of high-grade and low-grade mobilizationtechniques in the management of adhesive capsulitis ofthe shoulder: randomized controlled trial. Phys Ther.2006;86:355–368

30. Teys P, Bisset L, Vicenzino B; The initial effects of aMulligan’s mobilization with movement technique on rangeof movement and pressure pain threshold in pain-limitedshoulders. Manual Therapy 13 (2008) 37–42

31. Ginn KA, Herbert RD, Khouw W, Lee R. A randomized,controlled clinical trial of a treatment for shoulder pain. PhysTher. 1997;77:802-811.

32. Taylor M, Suvinen T, Reade P. The effect of grade IVdistraction mobilization on patients with temporomandibularpain-dysfunction disorder. Physiotherapy Theory andPractice. 1994; 10:129 –136.

33. Nicholson GG. The effect of passive joint mobilization onpain and hypomobility associated with adhesive capsulitisof the shoulder. J Orthop Sports Phys Ther. 1985;6:238 –246.

34. Donatelli RA: Physical therapy of the shoulder, 3rd edition,NewYork, NY: Churchill Livingstone Inc; 1997.


16

Home Environment as a Correlate of Development of Toddlers inBangaloreS Balsubramanian1, Y S Siddegowda2

1Associate Professor, Srinivas College of Physiotherapy and Research Centre, Pandeshwar, Mangalore, 2Professor, Dept. of Studiesin Social Work, University of Mysore, Manasagangotri, Mysore-570006

Abstract

Background

Children are born with a sophisticated brain that is pre-programmed to learn and react to its environment. Developmentin the first three years of life is incredibly quick. An optimal rangeof development occurs with a stimulating home environmentand strong contextual support.

Objective

To observe whether there is difference in home environmentbetween literate and illiterate parents living in urban and ruralareas of Bangalore and to correlate the same with the variousdevelopmental domains of children aged between one and threeyears old.

Design

Descriptive cross-sectional study design.

Materials and Method

Through multi-stage cluster random sampling fifty urbanfamilies with children aged one to three years old (25 familieswith both the parents literates and 25 families with both theparents illiterates) and fifty rural families with children aged oneto three years old (25 families with both the parents literatesand 25 families with both the parents illiterates) were recruitedfrom Bangalore urban and Bangalore rural districts respectively.The parental literacy status was assessed by using theoperational definition of literacy stated by UNESCO (UnitedNations Educational, Scientific and Cultural Organization). TheHome environment was measured by using Infant/ToddlerHOME (The Home Observation for Measurement of theEnvironment) Inventory. The development of the children wasassessed by using Denver II.

Results

Kruskal – Wallis analysis showed a statistically significantdifference among all the four groups in terms of their Homeenvironment (measured by HOME inventory) and developmentof children in various developmental domains (measured byDenver II) at a significance level of 0.05. Mann Whitney U Post-hoc analysis found that there was a significant differencebetween all the unique pair comparisons in at least one of thevariables except between the pair Urban illiterate and Ruralilliterate at a significance level of 0.0125. All the developmentaldomains were positively correlated with total score obtained in

Address for correspondence:S. BalasubramanianAssociate ProfessorSrinivas College of Physiotherapy and Research Centre,Pandeshwar, Mangalore, Ph-No: 0824-2411381E-Mail: [email protected]

home inventory for all the groups except for the Rural illiterategroup in Gross motor domain.

Conclusion

The Home environment differs from urban and rural familiesand also between literates and illiterates and further influencingthe development of children aged between one and three yearsold.

Keywords

HOME Inventory, Denver II, Toddlers, Development ofToddlers, Family environment.

Introduction

During the initial 2 years of life, there is a sequential growth,phenomenal proliferation, and overproduction of axons,dendrites, and synapses in different regions of the brain.However, not all the synaptic connections survive, many beingsubsequently “pruned” due to lack of use1. During this period ofplasticity, or potential for change, the determination of whichsynaptic connections will persist is environmentally regulated,being dependent on information received by the brain. Theprogressive neuronal maturation and the establishment ofsynaptic connections are reflected in changes in the infant’sincreasing functional maturity2.

Sensitive periods in brain and biological development startprenatally and continue throughout childhood and adolescence.The extent to which these processes lead to healthydevelopment depends upon the qualities of stimulation, support,and nurturance in the social environments in which children live,learn and grow3. Amongst the various social groups, the homeoccupies the first and the most significant place for thedevelopment of the individual4. Home environment has beenshown to be a major factor that influences the overalldevelopment of children. Availability of stimulating objects, booksand play materials within the home are critical indicators for theoverall quality of the home environment5.

Since many years, effort has been made to map therelations between the home environment and selected aspectsof the child’s development. For most children, interior of thehome and its immediate surroundings are the first environmentsthey experience throughout their early years5. The ecologicalenvironment is defined by Bronfenbrenner and Ceci6 as a set of“nested structures” composed of microsystems, mesosystems,exosystems, macrosystems and chronosystems. Themicrosystem is “a pattern of activities, roles and interpersonalrelations experienced by the developing person in a given settingwith particular physical and material characteristics; the homeenvironment including the parent-child relationship is an exampleof microsystem”7.

The recent theories of early motor development suggestthat the acquisition of new motor abilities arises from theinteraction of multiple elements of the infant, the environmentand the task at hand through a process of exploration ofmovement options and selection of the optimal solution in agiven context8. The home should have manipulatives thatencourage the young child to have a variety of sensory

S Balsubramanian / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

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experiences, and to be able to develop fine and gross motorskills9.

Parents who expose their preschoolers to problem-solvingstrategies are more likely to have children who use them10.Mothers who interact with preschool children in problem-solvingtasks, and expose them to open-ended questions about thattask, have children who later demonstrate greater independentperformance with similar tasks requiring problem-solving skills10.

High-achieving children have parents who read to themfrequently and help them attain phonemic awareness. In homeswhere children participate in family discussions, children arebetter prepared for the language they will hear in classrooms.Parent-child interaction with reading materials is important duringthe preschool period because it is during these years thatchildren become familiar with story structures, complex syntax,and vocabulary. They will be better prepared to develop conceptsthat are prerequisites to reading and listening comprehension.In order for reading ability to develop and remain constantthroughout the elementary school years, children must hear andpractice language from an early age11.

The measures of environmental quality (orderliness,enrichment and overall stimulating quality) and of parent-infantinteraction (mother-child interaction patterns, family habits, livingpatterns as described by the mother), taken in the first year oflife are the best predictors of later IQ or language performance12.In a 3-year longitudinal study conducted with 119 children in the1 to 4-year age group, a positive correlation was found betweencognitive development and the home stimulation variablesmeasured on the HOME scale13.

The early home environment is a significant prediction ofmental development and at the same time the home is ofextraordinary importance in the development of socialintelligence14-17. It is not only providing the hereditary transmissionof basic potential for child development but also providesenvironmental conditions and personal relationships18. Childrenfrom favorable environment homes are found to be warm-hearted, outgoing and socially more intelligent than children fromunfavorable homes19.

Families are the first environments with which childreninteract from birth. They are critically important in providingchildren with stimulation, support and nurturance20. Thesequalities, in turn, are influenced by the resources that familieshave to devote to child-raising (strongly influenced by income),their style of parenting, and their tendency to provide a rich andresponsive language environment (strongly influenced byparental levels of education)21.

A greater part of the Indian population lives in villages22.The infants get fewer opportunities to develop their fullprospective as their mothers lack knowledge regarding scientificchild care, stimulatory activities and conducive environmentwhich are essential for hale and hearty development. Appropriatecare and right kind of development opportunities for thissusceptible and immense section of population are decisivesince these have a direct demeanor upon the future humanresource development of a nation23. The parents’ educationallevels have an important impact on children’s achievement24,and higher levels of adult education have a positive bearing onboth the educational future and the income level of the childrenin a family25. Further, the children of mothers with higher levelsof education have greater early success and generally stay inschool longer26,27.

The present study was undertaken to observe whether thereis difference in Home environment of literate and illiterate parentsliving in urban and rural areas of Bangalore and to correlate thesame with the various developmental domains of children agedbetween 1 and 3 years old.


Design of the Study

Descriptive cross-sectional study design

Sampling

Fifty urban families with children aged one to three yearsold (25 families with both the parents literates and 25 familieswith both the parents illiterates) and fifty rural families withchildren aged one to three years old (25 families with both theparents literates and 25 families with both the parents illiterates)were recruited from Bangalore urban and Bangalore ruraldistricts respectively by multi-stage cluster random sampling.Thus totally four groups were formed.

Participants

From these 4 groups, at least one of the parents along withtheir children between 1 and 3 years had participated in thestudy. If there were more than 1 child in that age group in thesame family, one of the children were selected randomly by usinglottery method. The inclusion criteria was children between theage group 1 and 3 years, both the genders, born in term, normalbirth weight (2.5 kg to 3.5 kg), appropriate for gestational age.Children born with any congenital anomalies, neonatal seizures,perinatal asphyxia, neonatal hypoglycemia, intracranialhemorrhage, neonatal hyperbilirubinaemia (bilirubin > 20 mg/dland untreated), hypothermia, neonatal infections, andsepticaemia were excluded from the study. If the parents werenot certain about the above features or no medical reports wereavailable, the parents were asked whether the child was admittedin the Neonatal Intensive Care Unit (NICU) as admission of anewborn in NICU may be due to any of the above mentionedfactors under exclusion criteria.

Tools

The following tools were used for data collection:-√ For assessing parental literacy status operational definition

of literacy stated by UNESCO28 was used,√ Infant/Toddler HOME Inventory29

√ Denver II30

Procedure

After the approval of the Institution’s Ethical and ScientificReview Committee, an informed written consent was obtainedfrom all the parents who were willing to participate in the studyafter explaining the purpose and procedure of the study. Aftercompleting the preliminary assessment, the home environmentwas observed by using the Infant/Toddler version of HOMEInventory. The presence of primary caretaker (either or both ofthe parents) was ensured during the visit.

Results

For data analysis, statistical software SPSS (v 16) was used.Descriptive statistics were calculated for all the basiccharacteristics like age, height, weight, and head circumference.Levene’s test for equality of variances was used to determinethe homogeneity of the 4 groups, which reveals that all the fourgroups were homogenous in terms of age, height, weight, andhead circumference (Table 1).


18

Table 1: Descriptive statistics of basic characteristics

Basic Characteristics Mean ± SD P valueAge (in months) 23.95 ± 5.92 0.287Height (in cm) 85.81 ± 4.94 0.341Weight (in Kg) 12.00 ± 1.08 0.058Head Circumference (in cm) 47.77 ± 0.93 0.423

á > 0.05; SD: Standard deviation

Kolmogorov-Smirnov test of normality was done for thefollowing variables: Total Score in HOME Inventory, Gross MotorDomain, Fine Motor – Adaptive, Language, and Personal SocialDomain in Denver II. None of the variables assumed normaldistribution at P > 0.05.

Table 2: Kruskal – Wallis Analysis to determine the differencein medians for the study variables among the 4 groups

Study Chi-square df P valueVariables statistic

Total score in 50.25 3 0.000HOME inventory

Gross motor 17.61 3 0.001domain inDenver II

Fine motor – 8.65 3 0.034Adaptive domainin Denver II

Language in 10.36 3 0.016Denver II

Personal – 21.84 3 0.000Social domainin Denver II

á < 0.05; df: Degrees of freedom

Kruskal – Wallis test was performed to determine thedifferences in medians for the study variables (Table 2). Theresults suggested that all the variables were statisticallysignificant at P < 0.05. To examine the difference between theunique pairs Mann Whitney U test was used (Table 3). The groupcodes were allotted as follows: Urban Literate – 1, Urban Illiterate– 2, Rural Literate – 3, Rural Illiterate – 4.

Table 3: Mann Whitney U Analysis

Study Median Minimum Maximum IQR P valueVariables 1 vs 2 2 vs 3 3 vs 4 1 vs 3 1 vs 4 2 vs 4

Total score in 22.00 5.00 42.00 18.00 0.000 0.000 0.000 0.676 0.000 0.040HOME inventory

Gross motor 1.00 1.00 2.00 0.00 0.004 0.556 0.302 0.001 0.013 0.641domain in Denver II

Fine motor – Adaptive 1.00 1.00 2.00 1.00 0.387 0.013 0.006 0.091 0.253 0.779domain in Denver II

Language in Denver II 1.00 1.00 2.00 1.00 0.049 0.002 0.043 0.230 0.399 0.253

Personal – Social 1.00 1.00 2.00 1.00 0.061 0.009 0.000 0.389 0.001 0.093domain in Denver II

á < 0.0125

The Mann Whitney U post-hoc analysis revealed that therewas a statistically significant difference between Urban literateand Urban illiterate groups in total score in HOME inventory

(P=0.000), and Gross motor domain in Denver II (P=0.004); astatistically significant difference between Urban illiterate andrural literate groups in total score in HOME inventory (P=0.000),and Language domain in Denver II (P=0.002); a statisticallysignificant difference between rural literate and rural illiterategroups in total score in Home inventory (P=0.000), and Personalsocial domain in Denver II (P=0.000); a statistically significantdifference was found between Urban literate and Rural literategroups in Gross motor domain in Denver II (P=0.001); astatistically significant difference was found between Urbanliterate and Rural illiterate groups in total score in HOMEinventory (P=0.000), and Personal social domain in Denver II(P=0.001); no statistically significant difference was foundbetween Urban illiterate and Rural Illiterate groups in any of thevariables at P < 0.05.

The Spearman rho correlation was done for each domainin Denver II against Total score in Home inventory (Table 4).

A positive correlation was found for all the domains againstTotal HOME inventory score except for Gross motor domain inRural illiterate group where no correlation was found betweenthese variables. A significant correlation was obtained for all thedomains in Urban literate group against the Total NOMEinventory score.

Discussion

Development of child does not rely on one factor alone buton many factors, which promote or inhibit the child’sdevelopment. The nature and type of environment provided tochildren at tender age is very important for their overalldevelopment22.

Earlier research on the physical environment of homes andcommunities primarily focused on environmental hazards,environmental stress and impacts of poverty. This body ofresearch strongly pointed that physical aspects of the home suchas cleanliness, water, noise and pollution influence the overallhealth and development of children31,32. Recently, there has beenincreasing interest among researchers on the quality of homeenvironments and their impact on child development33-37.

During the investigation of three ethnic groups across thefirst three years of a child’s life Bradley et al38 found that measuresof particular aspects of the child’s home environment, such asparental response, and availability of stimulating play materialswere strongly related to children’s developmental status. Thefindings of another study confirmed that on the HOME scale,particularly accessibility of materials (play objects, reading books,musical instruments, picture decorations, and other educational

materials) was found to be a significant predictor of children’sperceived competence39.

The specific interaction of two features of the homeenvironment, availability of toys and amount of maternal


19

involvement were examined in 6 months old children and foundthat higher locomotor, eye-hand coordination and criticaldevelopmental quotients were associated with the additivecombination of more optimal play materials and high level ofmaternal involvement. When examining the independentcontribution of the factors, appropriate play materials wereassociated with more favorable eye-hand coordination40.

Parents and the literacy environments they create in theirhomes are widely believed to play an important role in thedevelopment of children’s reading and language skills. Evidenceto support this belief has often centered on the time that parentsspend reading to their children41. Scarborough, Dobrich, andHager42 found that preschoolers who were read to more andwho participated in more solitary book activities at home becamebetter readers by Grade 2 compared to preschoolers with lessfrequent early literary home experiences. DeBaryshe43 observedthat mothers who began reading to their children at an earlierage had children with greater receptive language abilities.

In developing countries, research consistently revealed thatthe assessment of home environments positively correlated withchildren’s cognitive and social development44. In Pakistan, homeenvironments were found to relate positively to the cognitivecompetence of children45. In Philippines, home environments of177 five and six-year-old preschool children were found to berelated to intellectual development46. It was also demonstratedthat the environmental factors and the home have significantinfluences on personality development in a Nigerian studyconducted by Odebunmi47.

Comparison of urban and rural sample revealed that urbanbabies, in general were better than rural in social skilldevelopment48.

The findings of all the above studies are in accord with theresults of the present study. This study correlated the Homeenvironment with the various developmental domains by takinginto account location of the residence (Urban or Rural) which isdecisive for the living standard and the parents’ literacy statuswhich is one of the influencing factors of the stimulating Homeenvironment. It is recommended to analyze the effects of otherfamily factors such as parenting style, type of family, and numberof siblings on the development of children aged between 1 and3 years old and to envisage the most influencing factor by aregression model.

Group Domains in Denver II rho P value

Urban Gross motor 0.499* 0.011Literate Fine motor - Adaptive 0.811** 0.000

Language 0.659** 0.000Personal - social 0.486* 0.014

Urban Gross motor 0.174 0.404illiterate Fine motor - Adaptive 0.331 0.106

Language 0.167 0.425Personal - social 0.318 0.121

Rural Gross motor 0.043 0.840Literate Fine motor - Adaptive 0.240 0.248


Rural Gross motor 0.000 1.000Illiterate Fine motor - Adaptive 0.302 0.142


Table 4: Spearman rho correlation

*Correlation is significant at the 0.05 level; **Correlation issignificant at the 0.01 level

Conclusion

The Home environment positively influences thedevelopment of the children aged between one and three yearsand which in turn is influenced by the location of the residencei.e., urban/ rural and the parental literacy status.

References

1. Singer W. Development and plasticity of cortical processingarchitectures. Science 1995;270:758-764.

2. Courchesne E, Chisum H, Townsend J. Neural activity-dependent brain changes in development: Implications forpsychopathology. Development and Psychopathology1994;6:697-722.

3. Richter L. The importance of caregiver-child interactionsfor the survival and healthy development of young children:A Review. Department of child and adolescent health anddevelopment, World Health Organization, CAH. 2004.

4. Harpreet Kaur, Ashu Kalaramna. Study of Interrelationshipbetween Home Environment, Social Intelligence and Socio-economic Status among Males and Females. J Hum Ecol2004;16(2):137-140.

5. Alireza Haydari, Parviz Askari, Maryam Zarra Nezhad.Relationship between Affordances in the HomeEnvironment and Motor Development in Children Age 18-42 Months. J Soc Sci 2009;5(4):319-328.

6. Bronfenbrenner U, Ceci SJ. Nature - nurture re-conceptualized in developmental perspective: Abioecological model. Psychol Rev 1994;101:568-586.

7. Bronfenbrenner U. The Ecology of Human Development:Experiments by Nature and Design. Harvard University,Cambridge, MA; 1981:348.

8. Thelen, E. Motor development: A new synthesis. Am Psychol1995;50:79-95.

9. Bradley RH, Caldwell BM, Rock SL. Home environment andschool performance: A ten year follow-up and examinationof three models of environmental action. Child Development1988;59:852-867.

10. Freund LS. Maternal regulation of children’s problem solvingbehavior and its impact on children’s performance. ChildDevelopment 1990;61:113-126.

11. Juel C. Learning to read and write: A longitudinal study of54 children from first through fourth grades. EducationalPsychology 1988;4:437- 447.

12. Helen L. Bee, Kathryn E. Bernard, Sandra J. Eyres, CarolA. Gray, Mary A. Hammond, Anita L. Spietz et al. Predictionof IQ and Language Skill from Perinatal Status, ChildPerformance, Family Characteristics, and Mother-InfantInteraction. Child Development 1982;53:1134-1156.

13. Gottfried A, Gottfried A. Home environment and earlycognitive development. Orlando, FL: Academic Press; 1984.

14. Fraster E. Home environment and the school. London,University of London Press; 1959.

15. Wilson SR. Synchronies in mental development: Anepigenetic perspective. Science 1978;202:439-57.

16. Desan PR. Individual differences and cultural differences.Bulletin de Psychologia 1980;33:12-15.

17. Maria KR, Piper MC. Effect of early home environment onthe mental development of Down Syndrome Infants. Am JMent Defic 1980;85(1):39-44.

18. Kundu CL. Personality development: A critique of IndianStudies. Rohtak, Visual Publication; 1977.

19. Rani S. A study of public school children’s psychologicaldevelopment in relation to home environment. J Indian Ed1998;16-23.

20. Pelto G, Dickin K, Engle P. A Critical Link, Interventions forphysical growth and psychological development: A Review.Department of child and adolescent health anddevelopment, World Health Organization, CAH; 1999.


20

21. Bronfenbrenner U. Ecology of the family as a context forhuman development: Research perspectives.Developmental Psychology 1986;22(6):723-741.

22. Goldy Chopra, Shubhangna Sharma, Shipra Nagar. TheImpact of Intervention on Motor and Mental Developmentof Rural Female Infants in District Kangra of HimachalPradesh. J Hum Ecol 2004;15(3):223-225.

23. Vander Z, James W. Human Development. New York,Academic Press; 1977.

24. Davie Ronald, Butler Neville R, Goldstein Harvey. Frombirth to seven. New York, Humanities press; 1972.

25. DeBruin-Parecki A, Paris S, Siedenburg J. Family literacy:Examining practice and effectiveness. J Adolesc AdultLiteracy 1997;40:596-605.

26. Sticht TG.”Adult Literacy Education.” Review of Researchin Education. 1988;15:59-96.

27. Sticht TG, McDonald BA. Teach the Mother and Reach theChild: Literacy Across Generations. Literacy Lessons.Geneva: International Bureau of Education. 1990.

28. Govinda R, Biswal K. Paper commissioned for the EFAGlobal Monitoring Report 2006, Literacy for Life. 2005 April.

29. Bradley RH, Caldwell BM. Home observation formeasurement of the environment: A validation study ofscreening efficiency. Am J Ment Defic 1977;81:417-420.

30. Frankenburg WK, Dodds J, Archer P, Shapiro H, BresnickB. The Denver II: A major revision and re-standardizationof the Denver Developmental Screening Test. Pediatrics1992 Jan;89:91-97.

31. Evans GW. The built environment and mental health.Journal of Urban Health: Bulletin of the New York Academyof Medicine 2003;80(4):536-555.

32. Guo G, Harris KM. The mechanisms mediating the effectsof poverty on children’s intellectual development.Demography 2000;37(4):431-447.

33. Ansell N, van Blerk L. “Where we stayed was very bad…”:Migrant children’s perspectives on life in informal rentedaccommodation in two southern African cities. Environmentand Planning A. 2005;37(3):423-440.

34. Evans GW. Child Development and the PhysicalEnvironment. Annual Review of Psychology2006;57(1):423-451.

35. Flores R. The effect of poverty on young children’s abilityto organize everyday events. Journal of Children andPoverty 2004;10(2):99-118.

36. Leventhal T, Selner-O’hagan, M, Brooks-Gunn J,Bingenheimer J, Earls F. The Homelife Interview from theProject on Human Development in Chicago

Neighborhoods: Assessment of Parenting and HomeEnvironment for 3- to 15-Year-Olds. Parenting: Science andPractice 2004;4:211-241.

37. Rodrigues L, Saraiva L, Gabbard C. Development andConstruct Validation of an Inventory for Assessing the HomeEnvironment for Motor Development. Research Quarterlyfor Exercise and Sport 2005;76(2):140-140.

38. Bradley RH, Caldwell BM, Rock, SL, Barnard K, Gray C,Hammond M, et al. Home environment and cognitivedevelopment in the first 3 years of life: A collaborative studyinvolving six sites and three ethnic groups in North America.Developmental Psychology 1989;25:217-235.

39. Lee J, Super CM, Harkness S. Self-perception ofcompetence in Korean children: Age, sex and homeinfluences. Asian J Soc Psychol 2003;6:133-147.

40. Bober SJ, Humphry R, Carswell HW, Core AJ. Toddlers’persistence in the emerging occupations of functional playand self-feeding. Am J Occup Ther 2001;55:369-376.

41. Evans MA, Shaw D, Bell M. Home literacy activities andtheir influence on early literacy skills. Can J Exp Psychol2000 Jun;54(2):65-75.

42. Scarborough HS, Dobrich W, Hager M. Literacy experienceand reading disability: Reading habits and abilities ofparents and young children. J Learning Disabilities1991;24:508-511.

43. Barbara D. Debaryshe. Joint picture-book readingcorrelates of early oral language skill. J Child Lang1993;20:455-461.

44. Selim Iltus. Paper commissioned for the EFA GlobalMonitoring Report 2007, Strong foundations: Earlychildhood care and education; 2006.

45. Masud S, Luster T, Youatt J. Predictors of homeenvironment and cognitive competence during earlychildhood in Pakistan. Early Child Development and Care1994;100:43-55.

46. Church A, Katigbak M. Home Environment, NutritionalStatus, and Maternal Intelligence as Determinants ofIntellectual Development in Rural Philippine PreschoolChildren. Intelligence 1991;15(1):49-78.

47. Odebunmi Akin. Factors Which Influence the Developmentof Intelligence and Performance Among Nigerian Children.Elementary and Early Childhood Education Clearinghouse.Opinion paper; 1980.

48. Bimla Dhanda and Sudha Chhikara. BehaviourDevelopment in Babies: Its Improvement in Relation withEcological Factors. J Hum Ecol 2006;19(3):215-219.


21

A Study of Efficacy of Neuromuscular Electrical Stimulation inPost Anterior Cruciate Ligament ReconstructionBibek Adhya1, Pravin Yadav2, M. S. Dhillon3, Vijay Kumar4, Upendra Goswami5

1,2,5Physiotherapist, 3Professor(Ortho.) & H O D, 4Sports Scientist, Department of Physiotherapy, PGIMER, Chandigarh, PIN- 160012,India

Abstract

Introduction & Purpose of the Study

Surgical reconstruction with the bone patellar tendon bonegraft is most commonly performed surgery for Anterior cruciateligament(ACL) injury, patient with ACL reconstruction have beenreported to demonstrate a disproportionate loss of strength ofquadriceps muscle, but commonly used knee extensor musclestrengthening strategies are contraindicated initially. Thepurpose of this study is to study the effect of neuromuscularelectric stimulation with exercise protocol in rehabilitation of postACL reconstruction.

Material & Methods

The study design is experimental. The samples were takenfrom Department of Physiotherapy, PGIMER; Chandigarh .Thepatients with ACL reconstruction with bone patellar tendon bonegraft were selected. For outcome four scales were used(Cincinnati knee rating system, Lysholm knee score, Lowerextremity functional scale &Visual analogue scale). Also girthmeasurement, muscle power and ROM were taken to assessthe progress of the patient. A number of 20 subjects, agegroup18-40years, were randomly selected for this study.Subjects were divided in two groups, one group (Group A)combined with neuromuscular electrical stimulation (NMES,interrupted direct current) & exercise while other (Group B) withexercise protocol only. For electrical stimulation Ionostim musclestimulator (Physiomed electronic, Chennai, India) was used. Theintensity was up to tolerable limit and surge was used.Neuromuscular electric stimulation for 15 min daily 6 days aweek was given. The exercise time is of a one hour/day for sixdays a week. The duration of exercise was increased accordingto protocol with time interval. The entire patient (both groups)underwent 12 week rehabilitation program and assessed withspecific scales at 8th and 12th week interval.The statisticalanalysis was done by using student’s t-test.

Results

Inter group analysis shows non significant result (p>0.05).

Conclusion

On the basis of the present study, it can be concluded thatboth the conventional treatment and conventional rehabilitationprotocol with neuromuscular electrical stimulation are equallyeffective to regain the functional skills in post ACL reconstructionrehabilitation.

Address for correspondence:Bibek AdhyaDepartment of Physiotherapy,P.G.I.M.E.R., Chandigarh,PIN-160012, IndiaEmail: [email protected]. +919876044966

Key Words

Anterior Cruciate Ligament, Rehabilitation, NeuromuscularElectrical Stimulation.

Introduction

Surgical reconstruction with the bone patellar tendon bone(BPTB)1,2 graft is most commonly performed surgery for AnteriorCruciate Ligament (ACL) injury. Reconstruction is commonprocedure to allow the patient to return to their former activelifestyle. Clinicians face a dilemma because patient with ACLreconstruction have been reported to demonstrate adisproportionate loss of strength of loss of quadriceps muscle,but commonly used knee extensor muscle strengtheningstrategies are contraindicated. There has been substantialevidences that neuromuscular electrical stimulation can improvequadriceps femoris muscle strength and recovery in patientsafter ACL reconstruction.4,11

The electrical stimulation, Short Duration Interrupted DirectCurrent (SDIDC)1,3,4,5 helps to recruit more fibers, so when itwas incorporated with conventional rehabilitation protocol it helpsto gain muscle power easily which may not be possible byvolitional contraction only. This early regain of muscle powerhelped the subjects to start functional activities earlier.Specifically, electrical stimulation of the quadriceps femorismuscle with volitional exercise after reconstruction has beenshown to be more effective than volitional training only

The purpose of this study is to study the role ofNeuromuscular electrical stimulation (NMES) in ACL postsurgical rehabilitation.

Study Design & Methodology

The patients with ACL reconstruction with bone patellartendon bone graft (BPTB) were taken for this study. All thepatients referred from Orthopedics department to physiotherapydepartment were taken for rehabilitation. Informed consent wastaken from patients before starting the treatment. All the patientswere described about the mode of treatment .One group withcombined NMES and exercise while other with exercise protocolonly. All the patient underwent 12 week rehabilitation protocoland assessed with all the scales mentioned below at 8th and12th week interval.

For outcome four scales were used: Cincinnati knee ratingsystem(CKRS) ,Noyes et al, 1984 6; Lysholm knee score(LKS),Lysholm et al, 19827;Lower extremity functionalscale(LEFS),Binkley et al,1999 8;Visual analogue scale(VAS),Wewers . & Lowe 19909

20 subjects were taken for this study randomly. The patientswere taken at physiotherapy department, PGIMER, Chandigarh,after referral from orthopedics department.

Inclusion Criteria: Patient age group: 18-40 years. Patientafter ACL reconstruction with BPTB graft.Patient with injury ofother ligament and menisci of knee joint only.

Exclusion Criteria: Patient with associated fracture, injuries,dislocations. Patient having any systemic disease, neurologicaldisorder.

Groups: 2 groups were formed for study with equal numberof patients in each group.

Bibek Adhya / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

22

Gr. A – NMES(SDIDC) + Exercises& conventional protocol &Gr. B- exercises & conventional protocol.

Intervention Protocol: For Group A NMES and exercise wasgiven. Neuromuscular electric stimulation (NMES) for 15 mindaily 6 days a week was given. For electrical stimulation IontostimMuscle Stimulator (Physiomed electronic Pvt. Ltd. Chennai,India) was used. Pad electrodes were used for stimulation ofvastus medialis obliques (VMO). Short duration interrupteddirect current, the so called faradic current was used. The

Fig.1: Iontostim Muscle Stimulator

Fig 2: NMES along with dynamic Exercise

intensity was upto tolerable limit and surge was used. Theexercise time is of an one hour/day for six days a week. Theduration of exercise was increased according to progression intime period.Girth measurement, muscle power and ROM weretaken to assess the progress of the patient. All the scoring wasdone at 8th and 12th week. For Group B only exercise protocolwas followed same as above and scoring was done.

Post-reconstruction conventional ACL rehabilitationprotocol.( Brukner P et.al, 1993).10

0-2 weekNon weight bearing(NWB) to partial weight bearing(PWB)

crutch walking .Heel to toe pattern gait.75% weight bearing.ROMexercises for knee joint. Patellofemoral joint mobilization. Passiveflexion and extension . Avoidance of last 30º active extensionof knee. Ankle toe movements (Ankle pump). Quadriceps,hamstrings and glutei Isometrics .Self assisted hamstring andquadriceps exercise. Hip abduction and extension exercise.Straight leg raising with brace .Use limited motion knee brace.Cryotherapy. Leg elevation

2-5 week

Full weight bearing at end of 3rd week .ROM exercises(should be 110 º).PNF(Proprioceptive NeuromuscularFacilitation).Strengthening exercise for quadriceps ,hamstrings,calf muscles glutei, hip flexor and hip abductors. Squatting 1/4to 1/3.Closed kinetic chain exercises(CKC).Stationary cycling.Rocker board exercise.

5-8 week

Full weight bearing. No limited motion brace. Use kneecap .Active extension and flexion. Squatting up to half.Progressive resistance exercise(PRE).OKC (open kinetic chainand CKC (closed kinetic chain) exercise. Stretching ofquadriceps, hamstrings and calf. Cryotherapy. Hydrotherapy,swimming ,walking in shallow water. Step up step down .Lungesto practice

8-12 week

Continue all exercise mentioned above .Start leg press.Full squatting.PRE to continue. Increase time of cycling .Staticand mild jogging .Road bike at end of 12th week.

Student’s t-test was used for data analysis.

Comparison of both treatment groups on 8th & 12th week with different scales

Scales Inter Group analysis of different scales

8th weeks 12thweeks

t-value p-value t-value p-value

CKRS 0.855 p>0.05 1.192 p>0.05

LKS 0.177 p>0.05 1.067 p>0.05

LEFS 2.916 P<0.05 1.489 p>0.05

VAS 0.709 p>0.05 0.601 p>0.05

p<0.05= significant, p>0.05=non-significant


23

and hamstring muscles on gait and on strength of the thighmuscles. Journal of Bone and Joint Surgery (Am).1991;73: 1025–1036.

3. Wigerstad-Lossing I, Grimby G, Jonsson T, Morelli B,Peterson L , Renstrom P. Effects of electrical musclestimulation combined with voluntary contractions after kneeligament surgery. Medicine & Science in Sports &Exercise.1988; 20: 93–98.

4. Delitto A, Rose S J, McKowen J M, Lehman R C, ThomasJ A, Shively R A. Electrical stimulation versus voluntaryexercise in strengthening thigh musculature after anteriorcruciate ligament surgery. Physical Therapy.1988; 68: 660–663.

5. Draper V, Ballard L. Electrical stimulation versuselectromyographic biofeedback in the recovery ofquadriceps femoris muscle function following anteriorcruciate ligament surgery. Physical Therapy.1991; 71: 455–461.

6. Noyes FR, McGinniss GH , Mooar LA .Functional disabilityin anterior Cruciate insufficient knee syndrome. SportsMed.1984;1: 287-288.

7. Lysholm J, Gillquist J. Evaluation of knee ligament surgeryresults with special emphasis on use of a scoring scale.Am J Sports Med.1982;10: 150- 154.

8. Binkley JM, Stratford PW. The Lower Extremity FunctionalScale (LEFS), Scale development measurement propertiesand clinical application. Physical Therapy.1999; 79: 371-383.

9. Wewers ME , Lowe NK. A critical review of visual analoguescales in the measurement of clinical phenomena.Research in Nursing and Health.1990; 13: 227–236.

10. Brukner P, Khan K,editors. Clinical Sports Medicine.1st

Edition.McGraw Hill.1993.11. Eriksson E, Haggmark T. Comparison of isometric muscle

training and electrical stimulation supplementing isometricmuscle training in the recovery after major knee ligamentsurgery: a preliminary repon. Am J Sports Med.1979;7: 169-171.


Discussion

The statistical analysis shows insignificant result for allscales (p<0.05) except one result for LEFS. The electricalstimulation(NMES/SDIDC) in conjunction with conventionalrehab protocol shows no significant difference. Though Erikssonet al (1979) 11, Delitto et al (1988)4 studied and found thatelectrical stimulation prevent the muscle atrophy after major kneeligament surgery. They concluded that neuromuscular electricalstimulation helped to improve torque generating capability ofthe quadriceps femoris after operation on the knee ligamentsbut the fact is those finding were quantified by isokineticapparatus not by the functional parameters. The present studyhad some limitations that must be considered. The sample sizeconsidered for the study was small so generalizations are difficult.It would be of interest to evaluate the effectiveness of regularapplication of NMES to investigate whether an application ofNMES has a beneficial effect.

Conclusion

On the basis of the present study, it can be concluded thatboth the conventional treatment and conventional rehabilitationprotocol with neuromuscular electrical stimulation are equallyeffective to regain the functional skills in post ACL reconstructionrehabilitation.

References

1. Sisk TD, Stralka SW, Deering, MB , Griffin JW. Effect ofelectrical stimulation on quadriceps strength afterreconstructive surgery of the anterior cruciate ligament.American Journal of Sports Medicine.1987; 15: 215–220.

2. Snyder-Mackler L, Ladin Z, Schepsis A A , Young JC.Electrical stimulation of the thigh muscles afterreconstruction of the anterior cruciate ligament.Effects ofelectrically elicited contraction of the quadriceps femoris

24

Effect of Two Different Exercises Protocol For Fall Preventationin ElderlyChaitali Shah, Vaishali SutharParul Insitute of Physiotherapy,Limda,Vadodara

Abstract

Background And Objectives

The term “ageing” refers to the biological process ofgrowing older in a deleterious sense. Balance mechanismsdeteriorate with increasing age, sway increases. Poor balancehas repeatedly being shown to be a risk factor for falls in adults.The main objectives of this study are to compare theeffectiveness of different balance exercises in elderly.

Methods

All subjects were selected randomly for two experimentalgroups after screening them for inclusion and exclusion criteria.Both groups were treated with different exercises protocol twotimes a day for consecutive 30 days. All the subjects evaluatedby Tinetti balance and gait assessment scale before and afterthe intervention.

Study Design

Purposive controlled trial pre test and post testexperimental design.

Sampling Technique

Simple random sampling technique.

Outcome Measures

1. Tinetti balance scale2. Tinetti gait assessment scale

Results

The data was analyzed by using t – test. We reject the nullhypothesis as no difference was seen in balance performancein group-1 and group-2 after giving balance training for 30consecutive days. Subject in the training group – 1 will beimprove static as well as dynamic stability after giving exercisesin age group of 65 years and above.

Conclusions

The study shows improvement in balance performance ofelderly persons after 30 days in both groups. But group-1 showsstatistically significant improvement than group-2.

Key Words

Aging, Balance, fall, Tinetti balance and gait assessmentscale

Introduction

1. Ageing

Although everyone is familiar with ageing, defining it is notso straightforward. In fact, ageing can have a positive connotationas in “ageing wine”. In the context of senescence, and unlessotherwise noted, the term “ageing” refers to the biologicalprocess of growing older in a deleterious sense. Thechronological criterion to identify the old in America has beenset at 65 years.However, the onset of health problems of elderlymay occur in early 50s or may be only in 40s.The presentchronological criterion to identify the old may change in future,as the mean age of population increases each declare and moreindividuals live in to their ninth decades.

Elderly are further classified as:Young – old 65-75 yearsMiddle-old 75-85 yearsOld-old > 85 years

2. Balance

Balance is a state of equilibrium or parity characterized bycancellation of all forces by equal opposing forces. Balance is aset of biological strategies designed to maintain the body in erectposture. Balance and coordination depend on the interaction ofmultiple body organs and systems including eyes, brain andnervous system, cardiovascular system and muscles.

There are mainly three mechanisms responsible formaintaining balance. Under normal circumstances; the bodyundergoes oscillation around a fixed point known as the ‘swaypat’. As these balance mechanisms deteriorate with increasingage, sway increases.

1. Ocular Mechanism

Under normal circumstances, visual cues are constantlyused to correct minor deviation from the fixed point.

2. Vestibular Mechanism

The vestibular is mainly involved with rotator movementsof the head and neck, whereas the eolith organ is involved withacceleration and deceleration.

3. Proprioceptive Mechanism

Position sense is important for maintaining balnce. Sensoryinformation from proprioceptors in the central spine and majorweight-bearing joints may be impaired with ageing and arthritis.Failure of these mechanism leads to an increased like hood offalls.

Chaitali Shah / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

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Falls in Elderly

FALL

An event, that result in a person’s inadvertently coming torest on the ground or lower level with or without loss ofconsciousness of injury. This excludes falls from major intrinsicevent (seizure, stroke and syncope) or overwhelmingenvironmental hazard.

√ Falls are extremely common among the elderly populationaccounting for substantial morbidity and mortality.

√ Approximately 30% of people over the age of 65 fall eachyear.

√ In about 3% of falls, the older adult lies on the floor for atleast 20 min.

√ Up to 20% of community dwelling elderly persons fall eachyear in the U.S. and this figure has doubled ininstitutionalized ambulatory populations.

√ These falls have serious immediate as well as long termcomplications.

√ Nearly 200,000 aged Americans have a fracture of the hipeach year usually during a fall and often with little obviousenvironmental provocation.

√ About 10% of falls require hospitalization due to fracturesand other injuries.

√ Approximately 50% of fall injuries seen in an emergencyroom will have continued pain and mobility limitations.

Risk factors

Risk factors associated with the occurrence of falls in elderlyare classified as

(i) Intrinsic or host factors.(ii) Extrinsic or environmental factors.

Intrinsic Factors

√ Poor balance√ Weakness√ Foot problems√ Visual impairment√ Cognitive impairment

Extrinsic Factors

√ Poor lighting√ Slippery surface√ Obstacles√ No safety equipment√ Loose carpets√ Poly pharmacy

Aims and Need of Study

The main objectives of this study are to compare theeffectiveness of different balance exercises in elderly.

Age and lack of physical activity may both be responsiblefor a poor balance control. The risk of developing problems inone or more of the sensory, motor, or adaptive brain componentsof balance increases with age as the body is exposed todegenerative or infectious diseases, or the effect of injuriesaccumulated over a lifetime. Thus, balance problems amongolder adults are frequently caused by combinations of subtledegenerative, infectious or injury processes that individually notclinically significant. Some elderly individuals experiencingbalance problems have obvious medical diagnosis such asdiabetes, Parkinson’s disease, or even a stroke that is primarysource of the problem. Whether balance disorders results from

combination of subtle problems or obvious disease, clinical studyindicate that elderly fallers are different from their healthy age-matched counterparts and required medical treatment tomaintain their healthy age-matched counterparts and requiredmedical treatment to maintain their functional independence andquality of life.

Poor balance has repeatedly being shown to be a risk factorfor falls in community-dwelling older adults. Balance has threebasic dimensions-maintenance of a position, stabilization forvoluntary movements and reaction to external disturbances.Most injurious falls occur during the performance of routine dailyactivities such as walking, transferring, stopping, bending orreaching.

The elderly are among those at greater risk fordisequilibrium. Although the relationship between muscleweakness in old age and equilibrium maintenance would seemto be closely related, studies related to this topic are rare andincomplete.

Review of Literature

1. Gun Jahansson and Gun – Britt Jarnlo (1990) concludedthat 70-years old women improved their performancesignificantly when standing on one leg and were able towalk faster after a 5 week training period.

2. Orr R, Raymong J etal (2000) concluded that improvements,significantly greater than controls in balance performancefollowing progressive resistive exercise.

3. Tinetti et al. (1997) found a reduction in the rate of fallsamong community-dwelling older adults who participatedin a multifocal intervention project that included the use ofexercises to improve balance and ability to transfer safely.

4. James a. Judge, Robert H. Whipple etal (2000) concludedthat resistive or balance training did not improve maximalgait velocity or chair rise time in this sample of relativelyhealthy older persons.

5. Elsevier B.V (2009) concluded that use of Tinetti balancetest to screen older people at rist of falling in order to includethem in a preventive intervention.

6. L cipriany – Dacko, D. innerst (2009) concluded that fair togood realiability of balance portion of Tinetti’s performanceOriented Mobility Assesment scores occurred across manyraters of varied experience with a small amount of training.

7. M. Madureira, L. Takayama (2006) concluded that anintervention using balance training is effective in improvingfunction and static balance, mobility and falling frequencyin elderly women with osteoporosis.

8. Raiche m, Herbert R et al. (2000) concluded that, in aprospective study of 225 community dwelling people. 75years and older we tested the validity of the Tinetti balancescale to predict score at 36 or less identified 7 of 10 fallerswith 70% sensitivity and 52% specificity, with this cut – offscore 53% of the individuals were screened positive andpresented a two-fold risk of falling. These characteristicssupport the use of this test to screen older people at risk offalling in older to include them in a preventive intervention.

9. Dr. mark chignell et al. (2008) concluded that exercises inparticular, strength and balance training can not only improvefunctional independence but also reduce risk of falls.

10. How TE, Rochesterl et al. (2000) concluded that resistiveor balance training did not improve maximal gait velocity orchair rise time in this sample of relatively healthy olderpersons.

11. Shumway – Cook A, et al. concluded that a simple predictivemodel based on two risk factors can be used by physicaltherapist to quantity fall risk in community-dwelling olderadults. Identification of patients with a high fall risk can leadto an appropriate referral in to fall prevention program. Inaddition, fall risk can be used to calculate change resultingfrom intervention.


26

Design and Methodology

Study Design

This study design was a purposive controlled trial pre testand post test experimental design.

Sample Size & Sampling Method

Thirty subjects of 65 years or above were selected by meansof simple random sampling procedure.

Hypothesis

• Null hypothesis (H0) :• There is no significant difference in balance performance

after balance training between two groups.• Alternate hypothesis (Ha) :• There is a significant difference in balance performance

after balance training between two groups.

Study Population

The subjects who fulfilled the following criteria were takenas study population.

Inclusion Criteria

• Subjects of 65 years of above of both sexes were taken forthe study.

Exclusion Criteria

• Subjects with History of impairment of hip, thigh and knees,• Recent fracture or any injury to lower limb,• Inflammatory condition to lower limb,• Sensory Deficits,• Previous surgery to cranium, spine or lower limb,• Hyper mobility to ankle and knee joint,• Rheumatoid arthritis,• Any neurological problem,• Amputation or severe pain in the lower limb.

Outcome Measures

Tinetti Test

Balance of all the subjects was measured on 1st day andon 30th day by Tinetti test.

Group Allocation

The Experimental Group – 1

This group was treated with following exercises two timesa day for 30 consecutive days.√ Single leg standing,√ Tandem walking,√ Walking in “fig of 8”√ Beam walking

The Experimental Group – 2

This group was treated with following exercises two timesa day for 30 consecutive days.√ Walk : Sideways,

√ Normal Standing with Reaching Activities,√ Weight Shifting : side-to-side, forward-to-backward,√ Full Tandem Standing,

Material

√ Tinetti Balance Assessment tool√ Standard Chair without Armrest√ Paper, Pen, Pencil, Chock√ Scale, Measure tape√ Stop Watch√ Beam

Procedure

All subjects were selected randomly for two experimentalgroups after screening them for inclusion and exclusion criteria.All the subjects evaluated by Tinetti balance and gait assessmentscale before and after the intervention. Informed consent wastaken from each subjects before starting the treatment, thesubject was positioned comfortably and assessed thoroughlyabout their condition.

The Experimental Group 1

This group was treated with following exercises two timesa day for 30 consecutive days.√ Single leg standing with 30 second holding time, 5

repetitions for each side.√ Tandem walking on the path of 5 meters, 3 rounds.√ Walking in “fig. of 8” manner, 5 rounds.√ Beam (length: 93", height: 3.5") walking, 3 rounds.

The Experimental Group 2

This group was treated with following exercises two timesa day for 30 consecutive days.√ Walk: Sideways, on path of 20 meters 2 rounds.√ Normal Standing with Reaching Activities, 30 repetitions.√ Weight Shifting: side-to-side, forward-to-backward, 20 times

for both.√ Full Tandem Standing, 30 second holding time, 5

repetitions.

Tinetti Performance Oriented MobilityAssessment (POMA)

Description

The Tinetti assessment tool is an easily administered task-oriented test that measures an older adult’s gait and balanceabilities.

Equipment Needed

Hard armless chairStopwatch or wristwatch15ft walkway

Completion Time

10-15 minutes

Scoring

A three-point ordinal scale, ranging from 0-2. “0” indicatesthe highest level of impairment and “2” the individual’sindependence.


27

Total Balance Score = 16Total Gait Score = 12Total Test Score = 28

Interpretation

25-28 = low fall risk19-24 = medium fall risk< 19 = high fall risk

Data Analysis

Graph 1:

Graph 3:

Graph 2:

Table 1:

GROUP 1 GROUP 2x1 x2

Mean 3.8 1.93

Table 2:

Tabulated value Calculated valuett tc

1.7010 4.70

Discussion

The Purpose of study is to see effect of balance trainingexercises in elderly. The data was analyzed by using t – test.We reject the null hypothesis as no difference was seen inbalance performance in group-1 and group-2 after giving balancetraining for 30 consecutive days.

Group – 1 is treated by balance exercises like Single legstanding, Tandem walking, Walking in “fig. of 8” and Beamwalking shows better balance performance than group – 2 whichis treated by Side walking, Standing with Reaching Activities,Weight Shifting : side-to-side, forward-to-backward, Full TandemStanding for 30 consecutive days.

The reason for significant difference may be,1. Propriception will increases with these balance exercises.

This is supported by the study done by,Gerome C.Gauchard , et.al. (2003) who concluded thatproprioceptive exercises appear to have the best impacton balance regulation and precision. Besides, even ifbioenergetics activity improves postural control in simpletasks, more difficult postural tasks show that this type ofactivity does not develop a neurosensorial. Proprioceptiveinput threshold as well, probably an account of highercontribution of visual afferent.

2. Specific muscles which will help body to maintain balancewill be trained through these exercises thus balanceimproves.This is also supported by the study done by, Kurt Murer,

et.al. (2007) who concluded twice – weekly lower extremitystrength training of 12 weeks duration in hostel – dwelling elderlyand lower extremity physical function when additional functionalexercises are added. The Tinetti Balance score and the chairstand test of the physical performance assessment improvedsignificantly.

Subject in the training group reported filling muchcomfortable after training and expressed a desire to continuethe exercise.

Finally, we found that age group of 65 years and aboveimprove their performance significantly on one leg and wereable to walk faster after 30 days training program. Thosesubjects who had the lowest before training showed the mostpronounced improvement.

Subject in the training group – 1 will be improve static aswell as dynamic stability after giving exercises in age group of65 years and above.

Limitation of the Study

• Sample size is very small. A large sample size is requiredto make the study morereliable.

• Limited time of data collection.• After completion the measurements are taken only of 30

days.• This study is limited to only one outcome measure other

outcome measures can also be used.

Further Suggestion for Research

• Studies can be conducted in larger sample.• Further followed by long-term follow up with same balance

activities.• Further studies are needed to determine if other outcome

measure can also be used (e.g. Berg Balance Scale).• Further studies can conducted with other balance activities

to see effect on balance by tinetti balance scale.

Conclusion

Thirty subjects of age 65 years and above participated inthis study. The study shows improvement in balanceperformance of elderly persons after 30 days in both groups.But group-1 shows statistically significant improvement thangroup-2.


28

References

1. Agency for Healthcare Research and Quality and theCenters for Disease Control and Prevention. PhysicalActivity and Older Americans: Benefits and Strategies June2002. Available at: http://www.ahrq.govppip/activity.htm,Accessed 2003.

2. Chang JT, Morton SC, Rubenstein LZ, et al. Interventionsfor the prevention of falls in older adults: systematic reviewand meta-analysis of randomized clinical trials BMJ. 2004;328:680.

3. Hauer K, Specht N, Schuler M, et al. Intensive physicaltraining in geriatric patients after server falls and hip surgery,Age Ageing. 2002.

4. Keller C, Fleury J, Mujezinovic-Womack M. Managingcardiovascular risk reduction in elderly adults: by promotingand monitoring healthy lifestyle changes, health careproviders can help older adults improve their cardiovascularhealth. J Gerontol Nurs. 2003; 29: 18-23.

5. Lichtenstein MJ, Shields SL, Shiavi RG, Burger C. Exerciseand balance in aged women: a pilot controlled clinical trail,Arch Phys Med Rehabil. 1989; 70: 138-143.

6. Mazzeo RS, Cavanagh P, Evans WJ, et al. Exercise andphysical activity for older adults [American College of Sports

Medicine position stand]. Med Sci Sports Exerc 1998 ; 30 :992 – 1008

7. Shumway-Cook A, Gruber W, Baldwin M, Liao S. The effectof multidimensional exercises on balance mobility, and fallrisk in community-dwelling older adults. Phys Ther, 1997;77:46-57.

8 Timonen L, Rantanen T, Ryynanen OP, et al. A randomizedcontrolled trial of rehabilitation after hospitalization infrail older women: effects on strength, balance and mobility.

Scand J Med Sci Sports 2002; 12: 186 – 192.9 Tinetti ME, Baker DI, McAvay G, et al. A multifactoral

intervention to reduce the risk of falling among elderlypeople living in the community. N Engl J med. 1994;331:821-827.

10 US Department of Health and Human Services. PhysicalActivity and Health : A Report of the Surgeon GeneralAtlanta, Ga : US Department of Health and HumanServices, Centers for Disease Control and Prevention,National Center for Chronic Disease Prevention and HealthPromotion ; 1996.

11 Shumway-Cook A, Gruber W, Baldwin M, Liao S. The effectof multidimensional exercises on balance mobility, and fallrisk in community-dwelling older adults. Phys Ther, 1997;77:46-57.


29

Functional Performance in Community-dwelling Elderly People:Six-minute Walk Test, Berg Balance Scale, Timed Up and Go Testand Gait SpeedsGarg Chaya, Sindwani VidhuBanarsidas Chandiwala Institute of Physiotherapy, Kalkaji, New Delhi-110019

Abstract

Background and Purpose

The interpretation of patient’s score on clinical tests ofphysical mobility in different age groups is limited by a lack ofdata describing the range of performance among people withoutdisabilities in the different age groups especially the elderlyadults. The purpose of this study was to provide data for thevalues of four clinical tests- 6 Minute Walk Test, Berg BalanceScale, Timed Up and Go test and Normal and Fast walkingspeeds in community dwelling older adults.

Subjects

Normal males and females (n=45) in the age group of 50-79 yrs with asymptomatic knee function were included in thestudy after they gave their informed consent.

Methods

The subjects were allocated to the three groups accordingto their age Group A (50-59 years), Group B (60-69 years), andGroup C (70-79 years). Subjects were told to wear comfortableshoes and were tested for: 6-minute walk test, Berg BalanceScale, Comfortable Gait speed, Fast Gait speed, Timed up andgo test.

Results

Using a Pearson product moment correlation test the resultsshowed a significant decline in performance for commonly usedperformance tests with increase in age in community-dwellingelderly people.

Conclusion

Age dependant normative values for performance testsshould be developed especially for commonly used tests likethe 6-Minute walk test, Berg Balance Scale, Gait speed and theTimed Up & Go test.

Key Words

6 Minute Walk Test, Berg Balance Scale, Timed Up andGo test, Normal and Fast walking speeds, community-dwellingelderly people.

Introduction

Examination at both the impairment level as well as at thefunctional level is very essential in the decision making processin physical therapy. The interpretation of patient’s score onclinical tests of physical mobility in different age groups is limitedby a lack of data describing the range of performance amongpeople without disabilities in the different age groups especiallythe elderly adults.

Many tests are available to assess the functional levels ofindividuals. Some of these tests have high levels of reliabilityand various aspects of validity have been established. However,limited data are available on the range of measurement of thesetests in different age groups. The normative values available forthese groups have been defined by testing of individuals of allage groups including the younger age group. Hence, the validityof these values in the elderly age groups is questionable. Thepurpose of this study was to provide data for the values of fourclinical tests- 6 Minute Walk Test, Berg Balance Scale, TimedUp and Go test and Normal and Fast walking speeds incommunity dwelling older adults.

The 6-Minute Walk test is a modification of the 12 minuteWalk-Run test1 as a field test to measure maximum oxygenuptake. It helps to test patients with pulmonary or cardiovasculardiseases, also to predict morbidity or mortality in patients withleft ventricular dysfunction2, advanced heart failure or chronicobstructive lung diseases3.

The Berg Balance Scale was developed as a performance-oriented measure of balance in elderly individuals4. It helps toidentify elderly persons who are at a risk for falling and referringpersons who are prone to falls for physical therapy for gait,balance and strength deficits. Several studies have shown thata baseline score contributes to discriminating between elderlypeople who are prone to falling and those who are not5. However,sufficient data is not available to describe the expected declinein performance according to increase in age. Riddle andStratford6 demonstrated that using the recommended cut offscore of 45 on the scale was relatively poor for identifying peoplewho are at-risk for falling (sensitivity = 64%) but relatively goodfor identifying people who are not at risk for falling (specificity =90%).

The Timed Up and Go test was developed originally as aclinical measure of balance in elderly people and was scoredon an ordinal scale of 1 to 5 based on an observer’s perceptionof the performer’s risk for falling during the test7. Podsiadlo andRichardson8 modified the original test by timing the task ratherthan scoring it qualitatively. According to their study, normalhealthy elderly usually complete the task in 10 seconds or less,very weak or frail elderly with poor mobility may take 2 minutesor more. Scores were interpreted as dŠ10 seconds as normal,dŠ20 seconds as good mobility (can go out alone, mobile withouta gait aid)and < 30 seconds – problems (cannot go out alone, requires agait aid). Hughes9 found a mean TUG score of 13.05 seconds inelderly people, aged 65-86 years. There is no consensus in theliterature regarding the effect of aging on TUG scores10.

Gait speed is a quick, inexpensive and a highly reliablemeasure of functional capacity that can be easily measured inthe clinical setting. Because elderly people frequently utilizephysical therapy services to achieve the maximum functionalability, the collection of gait analysis data of healthy elderlysubjects is essential to establish realistic rehabilitationexpectations of the elderly population. Regardless of themeasurement method, gait speed measurements are consideredhighly reliable in people without known impairments that shouldaffect gait and different patient populations.

Average gait speeds for subjects without knownimpairments over 60 years of age have ranged from 0.60 to

Garg Chaya / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

30

1.45 m/s for comfortable walking speeds and 0.84 to 2.1 m/s forfast walking speeds11. Older adults without known impairmentsare reported to be able to increase their walking speed from21% to 56% above a comfortable pace when instructed12.

Methodology

Normal males and females (n=45) in the age group of 50-79 yrs with asymptomatic knee function were included in thestudy after they gave their informed consent. Subjects wereexcluded from the study if they had history of smoking, dizziness,unable to tolerate standing and walking for 6 minutes withoutshortness of breath, chest pain or joint pain in the legs, neck orback, were using any assistive aid for walking were undergoingany weight training or conditioning.13. The subjects were allocatedto the three groups according to their age:• Group A: 50-59 years• Group B: 60-69 years• Group C: 70-79 years

The data was collected for each subject within one session.Subjects were told to wear comfortable shoes for the test session.Demographic data was collected (age, height, weight, medicalhistory, heart rate and resting blood pressure). The tests wereadministered to each subject in the same order1. 6-minute walk test2. Berg Balance Scale3. Comfortable Gait speed4. Fast Gait speed5. Timed up and go

6-Minute Walk Test

It was conducted along a walkway marked with 1mincrements. A line was made at each end of the walkway toindicate where the subject was to turn. Subjects walked aloneduring the 6-minute walk unless the researcher felt that theywere unsafe. Subjects were instructed to ‘walk as far as possible’in 6 minutes. Each subject had a practice trial and then resteduntil the heart rate returned to the baseline level followed by asecond test trial, the distance for which was recorded as it hasbeen shown that the 2nd trial produces more appropriate results14.

Berg Balance Scale

The 14 activities were scored on a scale of 0 to 4. Score of0 was given if the subject was unable to do the task and a scoreof 4 if the subject was able to complete the task based on thecriterion that has been assigned to it. The maximum total scoreon the test was 56. The items included various simple mobilitytasks (e.g. transfers, standing unsupported) and more difficulttasks (e.g. tandem standing, turning 360 degrees)15

Gait Speeds

2 consecutive trials at each of the gait speeds were done.Data were collected as each subject walked on a marked 10 mwalkway at:a Normal comfortable speed andb Fast speed.

Gait speed was measured with a stop watch. The 2 trials ateach speed were averaged for use in data analysis13.

Timed Up and Go Test

The timed up and go test16 was administered using a firmchair with arm rests. A distance of 3m was marked off on thefloor in front of the chair. The test began with each subject sittingwith back against the chair, arms resting on the lap and feetbehind the distance marker on the floor. Subjects were instructedas “on the word ‘go’, stand up, walk comfortably and safely to

the 3m mark, turn, come back and sit all the way back in thechair”. They were informed that the trial would be timed. Timingbegan on the word ‘go’ and ended when the subject’s back restedagainst the chair upon returning. A practice trial was performedfollowed by 2 record trials. Data obtained during the 2 trials wereaveraged for use in data analysis.

Results

The basic characteristics of the three groups were assummarized in table: 1. The test results for the three groups aresummarized in table: 2.

6-Minute Walk Test

There was an age group*test score interaction with F (2,42) = 6.451, p<0.01. Post hoc analysis revealed that ascompared to the Group 1 both the groups had higher test scoresfor SMWT but group 3 had significantly higher test scores.Whereas the difference between the group 1 & 2 and Group 2 &3 were found to be non-significant. (Fig 1)

Using a Pearson product moment correlation test on data(r = -0.433), the results were significant (p<0.01, for two tailedtest) indicating a highly significant negative correlation in SMWTand age. (Fig 2)

Fig. 1: Comparison of 6-Minute Walk Test

Fig. 2: Correlation of 6-Minute Walk Test with Age

Berg Balance Scale

There was an age group*test score interaction with F (2,42) = 23.349, p<0.01. Post hoc analysis revealed that ascompared to the Group 1 both the groups 2, 3 had significantlyhigher test scores. Also the difference between the Groups 2 &3 was found to be significant. (Fig 3)

Using a Pearson product moment correlation test on data(r = -0.713), the results were significant (p<0.01, for two tailedtest) indicating a highly significant negative correlation in BergBalance Scale score and age. (Fig 4)


31

Comfortable Gait Speed

There was an age group*test score interaction with F (2,42) = 7.825, p<0.01. Post hoc analysis revealed that ascompared to the Group 1 both the groups 2, 3 had significantlyhigher test scores. Whereas the difference between the Groups2 & 3 were found to be non-significant. (Fig 5)

Using a Pearson product moment correlation test on data(r = -0.519), the results were significant (p<0.01, for two tailedtest) indicating a highly significant negative correlation inComfortable Gait Speed and age. (Fig 6)

Fig. 3: Comparison of Berg Balance Scale

Fig 4: Correlation of Berg Balance Scale with Age

Fig. 5: Comparison of Comfortable Gait Speed

Fig. 6: Correlation of Comfortable Gait Speed with Age

Fast Gait Speed

There was an age group*test score interaction with F (2,42) = 15.164, p<0.01. Post hoc analysis revealed that ascompared to the Group 1 both the groups 2, 3 had significantlyhigher test scores. Whereas the difference between the Groups2 & 3 were found to be non-significant. (Fig 7)

Using a Pearson product moment correlation test on data(r = -0.641), the results were significant (p<0.01, for two tailedtest) indicating a highly significant negative correlation in Fast

Fig. 7: Comparison of Fast Gait Speed

Fig. 8: Correlation of Fast Gait Speed with Age

Gait Speed and age. (Fig 8)

Timed Up And Go Test

Analysis revealed that there was no significant differencebetween the three groups in the scores for TUG with F (2, 42) =2.564, p=0.089. (Fig 9)

Using a Pearson product moment correlation test on data(r = 0.364), the results were significant (p<0.05, for two tailedtest) indicating a positive correlation in Timed Up and Go Testand age. (Fig 10)

Fig. 9: Comparison of Timed Up & Go Test


32

Table 1: Basic characteristics of group

Age Height WeightGroups Mean Mean Mean

(SD) (SD) (SD)

A 54.67 1.56 66.87(2.81) (0.15) (7.43)

B 63.60 1.51 67.13(2.92) (0.21) (11.15)

C 74.93 1.53 66.87(3.03) (0.20) (8.67)

Table 2: Comparison of test results of the 3 Groups

Groups 6-Minute Walk Berg Balance Comfortable Fast Gait Timed UpTest (in meters) Scale score Gait Speed Speed & Go (in

(in m/sec) (in m/sec) sec)

Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)A 309.78 (92.47) 51.27 (0.49) 1.11 (0.42) 1.58 (0.49) 10.59 (3.20)B 235.37 (112.54) 46.87 (3.81) 0.87 (0.17) 1.12 (0.24) 11.76 (2.79)C 191.06 (62.37) 43.93 (2.76) 0.72 (0.15) 0.94 (0.15) 13.21 (3.46)

Fig. 10: Correlation of Timed Up & Go Test with Age

Discussion

The normative values available for the four tests used inour study have been obtained by clinical trials on very large agegroups, including the younger age groups. This has resulted inreferring to the same values for assessing the younger as wellolder adults. However, all four tests in this study showed asignificant decline in performance with increase in age inCommunity-dwelling normal elderly people. Thus, thesepreliminary data suggests the need for using age-related valuesin order to make judgments for older adults.

A study13 showed similar results as our study. Themethodology of their study and the subject selection was similarto our study and hence the similar results. Although the actualvalues obtained for the different tests differ from our study, theyshowed a similar trend of decline in performance as our study.

Our mean data for the Berg Balance Scale are similar tothe score reported by Newton in 199717 for inner-city dwellingolder adults. The much wider range of Berg Balance Scale scoresfound by Newton suggests the fact that some subjects reporteda history of falling. Although Bogle-Thorbahn5 did not find arelationship between age and the Berg Balance Scale data in66 elderly people, our results suggest that age-related normsmay be needed for the Berg Balance Scale. This difference maybe due to the differences in population from which the subjectswere selected in our study and the study conducted by Bogle-Thorbahn and Newton. The subjects in both studies functionedindependently. The subjects in our study, however, lived in thecommunity, whereas those studied by them lived in life careinstitutes.

Our findings of the Timed Up and Go test fall within theranges reported by Podsiadlo D and Richardson S8 who alsoused a 3-m walking distance in their test protocol and did notinclude subjects who required an ambulatory device. Newton in199717 reported the highest mean Timed Up and Go scores (15seconds) and widest range of scores. The probable causes forthe higher scores could be that she used a 3.05 m walkingdistance in her protocol, a lower chair height than was used inother studies and included subjects who used an ambulatorydevice. The mean timed up and go score of our subjects weremuch faster than those obtained for hospitalized elderly patientsas reported by Nikolaus18. The obvious reason for this is thegreater amount of functional mobility and daily activity presentin community-dwelling elderly people as compared tohospitalized people.

One of the previous studies on gait speeds (11) used thesame stopwatch method and a similar distance as we did formeasuring gait speed. This stopwatch method of measuring gait

speed is easy and inexpensive, making it, in our view, clinicallyuseful. The ability to increase the walking speed from comfortableto fast shown by our subjects was similar to that found byBohannon.

Lipkin19 reported significantly higher 6-Minute Walkdistances as compared to our study. The probable cause forthis could be that they did not include a practice trial in theirprotocol.

Conclusion

Elderly adults represent a sizeable proportion of ourpopulation especially with increasing life span. This study showeda significant decline in performance for commonly usedperformance tests with increase in age in community-dwellingnormal elderly people. Therefore, age dependant normativevalues for performance tests should be developed especiallyfor commonly used tests like the 6-Minute walk test, BergBalance Scale, Gait speed and the Timed Up & Go test.

References

1. Cooper KH. A means of assessing maximal oxygen uptake:correlation between field and treadmill testing. JAMA. 1968;203:201-204.

2. Bittner V, Weiner DH, Yusuf S, et al. Prediction of mortalityand morbidity with a 6-minute walk test in patients with leftventricular dysfunction. JAMA. 1993; 270:1702-1707.

3. Kadikar A, Maurer J, Kesten S. The six-minute walk test: aguide to assessment for lung transplantation. J Heart LungTransplant. 1997; 16:313-319.

4. Berg KO, Wood-Dauphinee SL, Williams JI, Gayton D.Measuring balance in elderly: preliminary development ofan instrument. Physiotherapy Canada. 1989; 41:304-311.

5. Bogle-Thorbahn LD, Newton RA. Use of the Berg BalanceTest to predict falls in elderly persons. Phys. Ther. 1996;76:576-585.

6. Riddle DL, Stratford PW. Interpreting validity indexes fordiagnostic tests: an illustration using the Berg Balance Test.Phys Ther. 1999; 79:939-948.

7. Mathias S, Nayak US, Isaacs B. Balance in elderly patients:the Get Up and Go test. Arch Phys Med Rehabil. 1986;67:387-389.

8. Podsiadlo D, Richardson S. The timed Up and Go: a test


33

of basic functional mobility for frail elderly persons. J AmGeriatr Soc. 1991; 39:142-148.

9. Hughes C, Osman C, Woods AK. Relationship amongperformance on stair ambulation, Functional Reach, andTimed Up and Go tests in older adults. Issues on Ageing.1998; 21:18-22

10. Medley A, Thompson M. The effect of assistive devices onthe performance of community dwelling elderly on the TimedUp and Go test. Issues on Ageing. 1997; 20:3-6.

11. Bohannon RW. Comfortable and maximum walking speedof adults aged 20-79 years: reference values anddeterminants. Age Ageing. 1997; 26:15-19.

12. Elble RJ, Thomas SS, Higgins C, Colliver J. Stridedependent changes in gait of older people. J Neurol. 1991;238:1-5.

13. Steffen TM, Hacker TA, Mollinger L. Age and gender relatedtest performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up and GoTest and Gait speeds. Phys Ther. 2002; 82:128-137.

14. Steele B. Timed walking tests of exercise capacity in chroniccardiopulmonary illness. J Cardiopulm Rehabil. 1996;16:25-33.

15. Berg KO, Maki BE, Williams JI, et al. Clinical and laboratorymeasures of postural balance in an elderly population. ArchPhys Med Rehabil. 1992; 73:1073-1080.

16. Shumway-Cook A, Brauer S, Woollacott M. Predicting theprobability for falls in community-dwelling older adults usingthe Timed Up and Go test. Phys Ther. 2000; 80:896-903.

17. Newton RA. Balance screening of an inner city older adultpopulation. Arch Phys Med Rehabil.1997; 78:587-591.

18. Nikolaus T, Bach M, Oster P, Schlierf G. Prospective valueof self report and performance based tests of functionalstatus for 18-month outcomes in elderly patients. Aging ClinExp Res. 1996; 8:271-275.

19. Lipkin DP, Scriven AJ, Crake T, Poole-Wilson PA. Six minutewalking test for assessing exercise capacity in chronic heartfailure. Br Med J (Clin Res Ed). 1986; 292:653-655.


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A Case Report on the Role of Occupational Therapy in Revascularisedand Replanted Surgical Case of Flexor Tendon of HandDeepak GanjiwaleOccupational Therapist, K.M.Patel Institute of Physiotherapy Shree Krishna Hospital, Karamsad, Anand, Gujarat, India

Abstract

Occupational Therapy intervention, after revascularisation/replant of flexor tendon injury, are very rare . When a primaryrepair can not be done, tendon reconstruction remains thetreatment in such cases. In the past years there have beensignificant innovations in injury repair and aftercare for patientswho sustain different zones of flexor injuries. Based onimprovements in our understanding of the mechanism of repair,new differentiated concepts have been developed, but activeextension and passive flexion is still the standard in flexor tendonsurgery. The new stronger suture techniques today allowimmediate active flexion and rehabilitation through Occupationaltherapy can help in improving the flexion movements faster.

The purpose of this article is to review the occupationaltherapy intervention of flexor tendon injury afterrevascularisation / replant.

A case of lacerated wound on right hand, volar aspect nearwrist with palmaris longus, flexor carpi ulnaris(FCU), flexor carpiradialis(FCR), flexor digitorum profundus(FDP), flexor digitorumsuperficialis(FDS), flexor pollicis longus(FPL), ulnar nerve andvessels cut, came to our centre . The tendons were repairedand patient was referred for occupational therapy services. Afteroccupational therapy intervention patient now is able to workindependently and has returned to his job back. Even thoughall the flexor tendons had got cut completely, the patient is todayable to perform all functions that he used to do before theaccident, again viz: drilling and cutting etc.

Key Words

Occupational therapy, Replant, Revascularisation.

Introduction

Restoring digital function flexor tendon injury continues tobe one of the great challenges in hand therapy.When a primaryrepair of the flexor tendon is not possible , tendon reconstructionbecomes the treatment of choice. Since past several years,there have been significant innovations in injury repair andaftercare for patients who sustain different zones of flexor injuries.Based on improvements in our understanding of the mechanismof repair, new differentiated concepts could be developed. Activeextension, passive flexion as introduced by Kleinert1 is still thestandard in flexor tendon surgery. New stronger suturetechniques today allow immediate active flexion. Here in thepresent case all flexor parts including artery and vessels werereceived in completely cut condition. After the reconstructivesurgery, three approaches were used to rehabilitate throughOccupational therapy2

1 immobilization for 2 to 3 weeks before beginning activeand passive mobilization

2 early passive mobilization3 early active mobilization with ADL’s training programme .

There are several cases available in the published historyof flexor tendon repair and rehabilitation3,4,5,6 , but none of thestudies have used occupational therapy solely as a formula toimprove the flexion movement.

Case presentation

The present case is of a 22years young man was workingin Gujarat he came with lacerated wound of RT hand, volaraspect near wrist with palmaris longus, flexor carpi ulnaris, flexorcarpi radialis, flexor digitorum profundus, flexor digitorumsuperficialis, flexor pollicis longus, ulnar nerve and vessels on22-06-2010 he was operated (tendon replant andrevascularisation of artery ) on the same day. later he wasdischarged from the hospital on 01/07/2010 and was called forOccupational Therapy treatment on OPD basis from 17-08-2010 till 18/09/10.

During the first assessment the patient had very poor grossand fine grip and also limited range of motion. (Table 1)

In wrist his range was 30 degree in flexion and 5 degree inextension , ulnar deviation and radial deviation were 0 on 17/08/10 but on 18/09/10 flexion was increased 50 active and 55degree in passive , extension range 15 degree in active and 20degree in passive . ulnar deviation 5 and radial deviation 5degree.(Table 2)

During sensory examination 2PD test was 8mm at ringfinger and he could not feel any sensation at the little finger tip.Touch sensation: there was Anaesthesia at the little and ringfinger at volar aspect and Paraesthesia at the 2nd, 3rd and 4th tipof the finger at dorsal aspect. After sensory integrationprogramme sensation improved a little , Tinel sign was presentat > 1 inch from the site of cut. After surgery patient had takentab analgesic for 15 days.

OT intervention was initially focused on active and passiveexercise of MCP joints only. After getting the minimum functionalrange, efforts on improving PIP and DIP joint were started. Alongwith this, ultrasound over the operated area was given andalso the patient was trained for the activities of daily living (ADL)for self care and tools modification.

Discussion

The current case is special in the sence that in all thepreviously published materials only tendon was seen completelycut and also the patient was rehabilitatitaed through multispeciality techniques viz various contributatuin of OT,PT,ortheosis and prothesis etc (ref 5) whereas in the current caseall the nerves, various arteries ,tendon of flexor compartmentcut when the patient came for the first time and after therevascularisation and replant of nerve and tendon (reconstructivesurgery)the patient was rehabilitated with Occupational Therapyalone along with OT only resting splint was given to the patientfor support at the initial stage only. At the end of the interventionfor a period of 1 month 4 days.

Conclusion

From the impovement in the functions of the injured handof the patient(tables 1,2), it is evident that OT alone can alsoplay a remarkable role in rehabilitation of such difficult cases.similar studies should be done to explore the role of OT inextensor group of muscles too.

Deepak Ganjiwale / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

35

Table 1: At the time of first assessment on 17/08/10

*Gross movement strength measured by JAMAR hand dynamo meter** Fine movement strength measured by JAMAR pinch o meter

Right hand Left handGross movement 2+2+2=2 kg 10+12+10=10kg

strength*

Fine movement Pad to pad 2 +2+2=2 pounds 10+10+10=10 poundsstrength**

Lat. Pinch 2+2+2=2 pounds 10+10+10=10 pounds

Tripod 2+2+2=2 pounds 10+10+10=10 pounds

Tip to tip 1+1+1=1 pounds 10+10+10=10 pounds

Range of Motion (Hand) MCP PIP DIP MCP PIP DIPThumb A 20 30

P 50 60Index A 20-50 25-50 10

P 70 60 40Middle A 30 60-70 25-45

P 55 70 50Ring A 20 70-85 25-50

P 45 85 60Little A 30 50-70 15-20

p 50 80 30

Table 2: At the time of final assessment on 18/09/10

Right hand Left handGross movement 6+6+4=5.3kg 10+12+10=10kg

strength*

Fine movement Pad to pad 6 pounds (mean of 3 trials ) 10+10+10=10 poundsstrength**

Lat. Pinch 8 pounds (mean of 3 trials ) 10+10+10=10 pounds

Tripod 8 pounds (mean of 3 trials ) 10+10+10=10 pounds

Tip to tip 4 pounds (mean of 3 trials ) 10+10+10=10 pounds

Range of Motion (Hand) MCP PIP DIP MCP PIP DIPThumb A 40 35

P 65 65Index A 10-80 35-100 35

P 100 110 80Middle A 65 70-100 20-65

P 90 110 90Ring A 55 70-100 20-50

P 80 110 70Little A 35 50-100 15-40

p 80 110 70

*Gross movement strength measured by JAMAR hand dynamo meter** Fine movement strength measured by JAMAR pinch o meter

Acknowledgement

I would like to thank to Dr. Saranjeet singh (orthopaedicsurgeon – specialist in hand reconstruction surgery )whooperated the case ,for his support and my wife Mrs. JaishreeGanjiwale (Asst. Professor – Biostatistics ) for all her help inmanuscript writing and adding valuable suggestion for this report.

References

1. Hahn P, Jacobs C, Müller-Zimmermann A. Rehabilitation afterflexor tendon surgery,Orthopaedic. 2003 May; 32(5):365-9.

2. Vucekovich K, Gallardo G, Fiala K. Rehabilitation after flexortendon repair, reconstruction, and tenolysis. Hand Clin. 2005May; 21(2):257-65.

3. Gelberman RH, Vandeberg JS, Manske PR, Akeson WH. Theearly stages of flexor tendon healing: a morphologic study ofthe first fourteen days. J Hand Surg [Am] 1985; 10:776–84.

4. Alba CD, LaStayo P. Postoperative management of functionallyrestrictive muscular adherence, a corollary to surgical tenolysis:a case report. J Hand Ther. 2001 Jan-Mar; 14(1):43-50.

5. Hunter JM.salisbury RE. flexor tendon reconstruction inseverely damaged Hand, J Bone Joint Surgery 53A:829, 1971.

6. Kessler I. The gasping technique for tendon repair, Hand 5:253,1973

Deepak Ganjiwale / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

36

Effect of Keyboard Slope and Forearm Support on UserPerformance and Comfort LevelDheeraj Lamba1, Babita Mishra2, Neetu Arya3, Shammi Chetan4, Saloni Priya5

1Incharge, 2,3,4,5Interns-Dept of Physiotherapy, IAHSET Medical College Haldwani

Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Introduction

Computers are ubiquitous and every computer has akeyboard for text and data-entry. In the past two decades,worldwide has experienced rapid growth in computer use inworkplace. This has led to increased incidence of related upperextremity cumulative trauma disorder which are injuries to softtissues of the body occur over an extended time period.

Cumulative trauma disorders (CTDs) are disorders of thesoft tissues(most frequently the tendons and nerves) due torepeated exertions and excessive movements of the body.Studies have suggested that there is an increased incidence ofmusculoskeletal disorders (MSDs) of the upper extremity incomputer users. Keyboard are the most frequent used computerinput device and most people have atleast some contact with akeyboard everyday. Proper placement (height and distance)design and use, and key usage are important characteristics toconsider for computer keyboard typing. Common measure usedto evaluate keyboard are posture, discomfort, keying force anduser acceptance.

Keyboard design research has focused on ulnar and radialdeviation, wrist extension, wrist support, forearm support, andshoulder and neck effects while using conventional keyboard,fixed and adjustable, split-angle keyboards.

Wrist extension, or positively angled, wrist and handorientation has become standard when discussing keyboardangle. This fact is eminent when considering the design of theconventional keyboards each row, from bottom to top, isconsecutively higher, results in positively sloped keyboard face.This design forces keyboard users to conduct tying taskspredominantly with wrist, hand and fingers extended. Only inthe past decade wrist flexion has become a consideration forkeyboard design in contrast to accepted standard, said to bebetween 0 degree and positive 25 degree slope.

Simononeau et al. showed that use of negative slopekeyboard angle downwards from +15 degrees to -15 degrees,mean wrist extension decreased approximately 13 degrees.

Cook et al. showed that provision of forearm support duringkeyboard and mouse has been demonstrated to reduce neckand shoulder muscles activity and also reduce ulnar deviationand less reports of discomfort than the floating condition.

Aims and Objectives

To determine the effect of different computer keyboard slopeangles and forearm support on user performance and comfortlevel.

Hypothesis

The use of negative keyboard slope with forearm supportwill increase the comfort level or ease of use and also preventWMSDs.

Methodology

Forty subjects with their mean age (28.17 + 3.8) year, meanweight (62.95 + 6.84) and mean BMI (5.63 + 0.20) participatedin this study. All subjects are professional typist and wererecruited from various part of the city. The purpose and procedure

of the study were explained to the subjects and a written consentwas taken.

The study was conducted in Department of Physiotherapy,IAHSET, Medical College, Haldwani.

Inclusion Criteria

1. Should be 10 digit “touch” typists and tying atleast 2 hourper work day.

2. All subjects will be able to type atleast 40 words per minute(WPM).

3. No prior history of hand/wrist injury, free of pain or discomfortrelated to typing.

4. Subjects: 18-45 years.

Exclusion Criteria

1. History of any wrist or finger.2. Cervical rediculopathy3. Neurological deficit4. Upper limb arthritis5. Anti inflammatory medications.

Design

Experimental design.

Instrumentation

1. 2 wooden block (2 cm wide, 12 cm long and 1 ½ cm height).2. Forearm support is build so that it is on the same plane as

the keyboard.3. An adjustable computer workstation (desk and chair) is

used.4. Tying test TQ 6.3 software – for collection of tying speed

and data accuracy.5. QWERTY keyboard.

Protocol

Based on the inclusion and exclusion criteria subjects wereincluded in this study. Participants were made to sit on a chair infront of the computer monitor. During the testing session all thesubjects were made to type 10 minutes with all the slopes (+7degree, 0 degree, -7 degree) with and without support. The tyingspeed and accuracy were measured for each subject. Ease-of-use and comfort data was collected after subjects typed on eachkeyboard angle. Each subject was made to rate keyboard overallcomfort and ease of use on a scale 1 to 6.

Procedure

Potential participants received a verbal and writtendescription about the project, its objectives and the proceduresused, and were asked to complete informed consent. A thoroughassessment was done to establish the absence of any workrelated musculoskeletal disorders (WMSDs) associated with thehands and wrist.

A three minutes pre-test tying was completed for assessing

37Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

typing proficiency. Participants were required to have a net tyingspeed of 40 words per minute using digit ‘Touch’ method.

Participants were made to sit on the experimental computerworkstation. The participants were seated in chair with a backrestin an upright position, in front of a video-display terminal (VDT)workstation that set up according to widely accepted guidelinesfor VDT workstations. Chair height was adjusted so that theknees formed a 90 degree angle and the feet were flat on thefloor. A footrest, keeping an elbow angle of approximately 80degree to 110 degree. Keyboard tray height was adjusted suchthat the elbow point was aligned with the wrist point, parallel tothe floor.

During testing session, all subjects were made to type onall 3 slopes (7 degree, 0 degree, -7 degree) with and withoutforearm support. Different participant were made to type atdifferent keyboard slopes randomly with or without forearmsupport and each participant was made to practice the typingtask at the particular slope for 3 minutes to allow participants tobecome accustomed to typing angle of the experimentalcondition. Then the participant typed for 10 minutes. Typing testTQ 6.3 was used to administer a pre-test typing task, practicetyping tasks, and test typing tasks for all experimental conditions.The programme provided text passages for participants torecreate. The task was limited to computer screen. Performancemeasures calculated by the software (i.e test duration, net typingspeed, typing accuracy and number of errors) were automaticallyrecorded for each condition in the form of reports. Ease of useand comfort data was collected after the participant typed oneach keyboard angle by subjects rated the keyboard overallcomfort and ease of use on a 1 to 6 scale. This procedure was

repeated until the subjects typed on the keyboard set at each 3angle with and without forearm support.

Data Analysis

Data analysis was done using SPSS – 12.0 version. Meanand standard deviation for age, weight and BMI calculated.

Oneway ANOVA was used to compare the speed, accuracy,error, comfort and ease of use at different degrees of keyboardtilts within group A and group B.

Independent t-test was used to compare at each degreesof keyboard angle (7, 0 and -7) between the group A and groupB for speed, accuracy, error, comfort and ease of use.

Significant level was set at p<0.05.

Results

Mean and standard deviation for age, weight and BMI wascalculated for subjects (Table 5.1)

Oneway ANOVA done to compare the variable at differentdegrees of keyboard slope within group A and group B, showedno significant differences in speed, accuracy and error, butshowed significant differences in comfort and ease of use (Table5.2 and 5.3).

Independent t-test used to compare different variable atdifferent degrees (7, 0 and -7) of keyboard slope between groupA and group B, showed no significant difference in speed,accuracy and error but significant difference seen in comfortand ease of use (Table 5.4).

Table 5.2: ANOVA between the variables at different degrees (7, 0 and -7) within Group A.

Variable 7 degree 0 degree -7 degree F PMean + SD Mean + SD Mean + SD Value Value

Speed 52.50 + 6.51 52.25 + 6.31 51.45 + 6.86 0.279 0.757

Accuracy 84.85 +7.42 85.88 + 7.65 85.45 + 6.88 0.199 0.820

Error 76.50 + 33.48 71.10 + 36.46 71.12 + 33.06 0.328 0.721

Comfort 5.15 + 0.92 4.45 + 0.67 5.10 + 0.92 8.436 0.0007

Ease 5.27+ 0.64 4.30 + 0.60 4.40 + 0.95 20.409 0.0005

Table 5.1: Mean and SD of age, weight and BMI for the subjects of Group A and Group B.

Age Weight BMIMean + SD Mean + SD Mean + SD

28.17 + 3.81 62.95 + 6.84 5.63 + 0.20

Table 5.3: ANOVA between the variables at different degrees (7, 0 and -7) within Group B.

Variable 7 degree 0 degree -7 degree F PMean + SD Mean + SD Mean + SD Value Value

Speed 53.00 + 6.55 52.12+ 6.89 50.52+6.25 1.459 0.237

Accuracy 86.24 + 7.00 84.34 + 7.17 83.29 + 7.54 1.713 0.185

Error 70.02 + 31.93 80.55 + 36.55 81.15 + 32.94 1.362 0.260

Comfort 4.75 + 0.70 4.45 + 0.63 3.95 + 0.67 14.341 0.0003

Ease 4.95 + 0.59 4.37 + 0.70 3.52 + 0.59 50.96 0.0001

38 Dheeraj Lamba / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Table: 5.4: Comparison of different 7 degree, 0 degree and -7 degree between Group A and Group B.

Variables Group A Group B T PMean + SD Mean + SD Value Value

Speed 52.5 + 6.51 53.0 + 6.55 0.342 0.733

Accuracy 84.8 + 7.42 86.2 + 7.00 0.865 0.390

7 degree Error 76.5 + 33.48 70.0 + 31.9 0.885 0.329

Comfort 5.15 + 0.92 4.7 + 0.70 2.178 0.032

Ease 1.27+ 0.64 1.9+ 0.59 2.349 0.021

Speed 52.25 + 6.31 52.1 + 6.89 0.085 0.933

Accuracy 85.8 + 7.65 84.3 + 7.17 0.924 0.358

0 degree Error 71.1 + 36.46 80.5 + 36.65 1.156 0.251

Comfort 4.45 + 0.67 4.4 + 0.63 0.000 1.000

Ease 4.3 + 0.60 4.3 + 0.70 0.510 0.612

Speed 51.4 + 6.86 50.5 +- 6.25 0.630 0.530

Accuracy 85.4 + 6.88 83.2 + 7.5 1.340 0.184

-7 degree Error 71.1 + 33.06 81.1 +32.94 1.358 0.178

Comfort 5.1 + 0.92 3.9 + 0.62 6.329 0.0004

Ease 4.4 + 0.95 3.5 + 0.59 4.908 0.0008

Discussion

The objective of the study was to determine the effect ofcomputer keyboard slope and forearm support on usersperformance and comfort level. It was hypothesized that negativekeyboard angle with forearm support would have significanteffects on users comfort level and ease to use and minimizedexposure to hypothesized risk factors for work relatedmusculoskeletal disorders.

The only hypothesis that is supported by this study is thatusing the forearm support increases the ‘comfort level’ and ‘easeto use’ when compared with ‘floating’ posture.

There was no significant change seen in tying performance(speed, accuracy and error) across all 3 keyboard slope withand without forearm support. Positive (+7 degree), neutral (0degree) and negative (-7 degree) with forearm support increasedthe comfort and ease of use. Hence the results does not supportexperimental hypothesis.

Typing Performance

There was no significant change in mean of typing speed,accuracy and error for all the slope with and without forearmsupport which indicate that subjects quickly adopted to new slopeangles, even after 3 minutes of practice.

The result of the study supports the pervious studiesconducted by Simoneau and Marklin R.W. and Hedge andPowers where they showed that keyboard with negative slopesdid not impair typing performance.

The studies done by Mitchell A. et al. showed an increasein typing performance at 10 degree keyboard angle, while othernegative angles (-20 degree, -30 degree )were comparable, itsnot better, than standard ( 7 degree). Hence, results of this studydisagree with the previous study.

The Ease of Use and Comfort

The ease of use and comfort showed that the keyboard at-7 without forearm support was rated least comfortable and mostdifficult to use of all the keyboard tested. Most comfortable andease of use rated for both negative keyboard slope (-7 degree)and positive (+7 degree) with foreram support.

The result of previous study is conducted by Gilad and Haralshowed that a negatively sloped keyboard was subjectivelyevaluated as more comfortable to the findings of the standardkeyboard configuration.

The findings n this study is similar to the findings ofSimoneau and Marklin R. W. that keyboard at -15 degree wasrated less comfortable and most difficult to use than keyboardwith at -7.5 degree, 0 degree and 7.5 degree.

Mitchell A. Woods found that level of difficulty for useincreased as the keyboard angle become more negative whencompared with the standard configuration.

Forearm Support

There was a significant increase in comfort and ease ofuse following use of forearm support. Cook and Burgess-limerickshowed that impact of forearm support on upper limb and wristposture and muscle activity during keyboard use was comparedwith a floating posture. Forearm support was led to a reductionin extreme ulnar deviation and reports of discomfort were highestfor the floating condition. Hence, this study supports their studies.

Providing forearm support is an effective intervention toprevent musculoskeletal disorders of upper limb and aids inreducing upper body pain associated with computer work.

Previous studies showed that the use of negative keyboardslope decreased wrist extension, forearm muscles activity anddecreased the key stick force; decreased carpal tunnel pressure

39

and there by prevented the upper limb musculoskeletaldisorders.

Studies showed that use of forearm support reduced neckand shoulder muscle activity less ulnar and radial deviation andsignificant decrease in neck, back, forearm and wrist discomfortand reduced upper body pain. Thereby providing of forearmsupport proves to be an effective intervention to preventmusculoskeletal disorders.

Alternative keyboard designs, which have long beenproposed as a way of reducing fingertip forces, repetition, orawkward wrist postures, would ideally reduce these known riskfactors without sacrificing productivity, comfort and ease of use.

Conclusion

The result of the study showed that using the forearmsupport increases the comfort level and easy to use whencompared with floating posture and also minimize exposure tohypothesized WMSDS. The keyboard slope with and withoutforearm support did not have any effect on speed, accuracyand error.

However, within the group results showed that the 6-pointcomfort and ease of use rating of the keyboard at 0 degree withforearm support is less comfortable and slightly easy to use iscompared with + 7 degree and -7 degree of keyboard angle.Keyboard of -7degree angle without forearm support showedless comfort and difficult to use compared with +7 degree and -7degree keyboard angle with forearm support.

It was evident from these results that one keyboard anglecould not be identified, based on multiple measures used andvarying results. Personal performance could decide which anglewas best on the subjective measure. However, this study

concludes a typing angle the range of +7 degree to -7 degreewith forearm support provides benefits compared to the floatingposture.

References

1. David Rempel, Elaine Sepina: The effect of keyboardkeyswitch make on applied force and finger flexor muscleactivity. Ergonomics 1997, 40(8): 800-808.

2. Thomas J. Armstrong, James A.: Investigation of appliedforces in alphanumeric keyboard work.Am.Ind.Hyd.Assoc.L. 1994, 55(I): 30-35

3. National Occupational Safety and health (NOSH) Facts.June 1997.

4. Cook, Robin Burgess Limerick: Foreram support forintensive keyboard users: a field study. Proceedings of HF,Melbouirne, Australia, 2002, 25-27.

5. Simoneau G.G., Marklin R.W.: Effect of computer keyboardslope and height on wrist extension angle. Human Factors,2001, 43(2): 1333-1349.

6. Mitchell A. Woods: effects of neative sloped keyboardwedges on user performance and perception. Industrial andSystems Engineering, 2007.

7. Alison Marks Anderson: Learning Curve Analysis forAlternative Keyboard. Industrial Engineering, Releigh, NorthCarolina.

8. William S. Marrs: Wrist motions in industry. Ergonomics,1999, 36(4): 341-351.

9. A. Zecevic, D.J. Miler and K. Harburn: An evaluation of theergonomics of three computer keyboard. Ergonomics, 2000,43(I): 55-72.

10. Anol Hedge et al.: Effects of multi touch keyboard in wristposture, comfort and typing performance. Jennifer Thom-Santelli, June 16, 2004.


120

repeating the test, a rest interval of 30 seconds was consideredbetween the trials. Test-retest repeatability was assessed afterone week for each subject and retest was done with the samemethod as test session.

EMG Recordings

Preparation of subjects’ skin for electrode placement wasdone in a standard fashion.EMG activity of five selected musclesincluding gluteus maximus(G.max),gluteusmedius(G.med),vastus medialis(VM),peroneus longus(PL) andmedial gastrocnemius(MG) were recorded using surface Ag/AgCl electrodes (10 mm in diameter, with the center-to-centerinterelectrode distance of 20 mm). The surface electrodes wereheld in place with double adhesive tape. A ground electrodewas placed on the medial malleolus of the subjects. Electrodeplacement was visually confirmed on monitor using manualmuscle testing techniques. An eight channel EMG system(datalink system, biometrics Ltd.,UK) recorded muscle activityduring the test, and raw EMG were checked for artifacts at thestart of each recording session.

Data Analysis

Data were collected for four successful jump-landing trialsin test and retest sessions. EMG signals were band-pass filteredat 20-450 Hz. The gain of the system was 1000×. The samplingfrequency of the EMG dada was 1000 Hz for each channel andthey were stored in a portable computer for offline analysis. Thesynchronization of the EMG and the force plate systems wasdone by starting the two measurement systems with a commonelectrical trigger signal. The onset time of muscle preactivationrelated to the landing moment was determined. The criteriasuggested by Santello were used10. The onset time of EMGactivity of each muscle under study was defined as the instantin time in which the distance between the integrated normalizedEMG signal inclination and the reference line was the highest10.

Mohammad Sadeghi Goghari / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

The average value of four trials was applied for statistical analysisand assessment of reliability.


Paired t-test between test and retest mean scores werecalculated to verify the absence of systematic bias and alphalevel was set at 0.05 for all statistical analysis.

Relative reliability was assessed using the (3, 4) model ofIntraclass Correlation Co-efficient (ICC3, 4). According to Munro’sclassification of reliability co-efficient, the degree of reliabilitywas interpreted11. For each ICC, 95% confidence interval (CI)was calculated to take the sampling distribution into account.To assess absolute reliability, the standard error of measurement(SEM) was calculated as the square root of the mean squareerror term derived from of the analysis of variance table6. Inaddition, the co-efficient of variation (CV) was determined forcomparison of absolute reliability between EMG variables of testand retest sessions (SD /mean *100). This was achieved bycalculating the mean of CV from individual CVs 6. SPSS version17 (SPSS Inc.) was used for statistical analysis.

Results

Table 1 depicts the mean and standard deviation (SD), ICC,95% CI, CV and SEM values of the onset time of five lower limbmuscles obtained for test and retest sessions during forwardjump-landing.

As illustrated, there was no significant difference betweentest and retest mean scores for any onset timing measures,which indicated the absence of any systematic bias (p > 0.05).During the jump-landing task, high and very high reliability wasfound for G.max, G.med, VM, PL, MG onset times of preactivationwith ICC level of .80, .72, .92, .91 and .80 respectively. The CVsof all onset times of muscle preactivation were less than 10%except for G.med and MG (14.72% and 11.50% respectively).The most consistent measure was PL onset time (8.16%) andthe most variable measure was G.med onset time (14.72%).

Table 1: test-retest intra-class correlation coefficients (ICC) with 95% confidence interval (CI), coefficient of variation (CV) andstandard errors of measurement (SEM) of onset time variables during jump-landing

Variable Test Retest ICC 95%CI SEM CV (%)

mean± SD (ms) mean± SD (ms)

G.max onset -171.91±43.47 -167.08±53.92 .80 .32-.94 19.44 9.03

G.med onset -118.41±34.63 -110.08±44.28 .72 .05-.92 18.32 14.72

VM onset -98.5±23 -95.5±27.17 .92 .73-.97 6.50 8.71

PL onset -118±28.64 -114.08±29.87 .91 .72-.97 8.59 8.16

MG onset -120.83±24.53 -114.5±24 .80 .34-.94 10.97 11.50

Note: SD=standard deviation; ms=millisecond; G.max=gluteus maximus; G.med=gluteus medius; VM=vastus medialis; PL=peroneuslongus; MG= medial gastrocnemius

Discussion

The purpose of the present study was to investigate thereliability of the onset timing of lower limb muscles’ preactivationduring landing in volleyball players with FAI. To our knowledge,this research is the first study which reported the consistency ofthe onset timing of lower limb muscles’ preactivation during afunctional and dynamic task such as jump-landing in athleteswith FAI. The results obtained show high to very high reliabilityof the EMG onset timing measures in the jump-landing task.This suggests that our measurement error was small andtherefore there is a limited probability of type II error (randomerror).

High reliability in this study may be due to several factors.Standardization of electrode placement in test and retest partsof this study may lead to increased probability of sampling fromthe same group or groups of motor units. This has beenhighlighted in previous studies12, 13. In this study, congenital bonylandmarks have been used to standardize the repositioning ofthe electrodes.

To prevent signal cross talk, electrodes were placed overthe center of muscle belly. It has been stated that whenelectrodes located over the center of muscle belly and in parallelwith muscle fibers, EMG signal is more reliable12-14.

40

Effect of Deep Cervical Flexor Strengthening on VerticalMandibular Opening on Subjects With Forward Head PostureDheeraj Lamba1, Satish Pant2, Girish Chandra3, Asha Joshi4, Divya Dalakoti5

1Incharge, 2,3,4,5InternsDept of Physiotherapy, IAHSET Medical College Haldwani


Introduction

The temporomandibular disorders (TMD) include a varietyof condition associated with pain and dysfunction of themasticatory muscles. An estimate 20% of population is affectedby this disorder. A wide variety of physical techniques includingjoint mobilization, exercise prescription, electrotherapy,education, biofeedback and relaxation, and postural correction,have been used in the management of temporomandibular joint(TMJ) disorders.

Vertical mandibular opening is measured by Interincisaldistance between edges of right upper and lower central incisorsas measurement with a millimeter ruler. The normal opening ofadults is between 35 to 50 mm i.e. 3.5 to 5 cm. but the functionalopening is 25 to 35 mm i.e. 2.5 to 3.5 cm or at least two knucklesbetween teeth.

The resting position of mandibular plays important role toproduce movement of vertical mandibular opening. In restingposition of mandibular, the lip is in light contact or slightly apart,the opposing teeth are separated, all the jaw muscles are atrest function and the mandible is passively suspended againstgravity.

Normally, no occlusal contact exit between the maxillaryand mandibular teeth when the muscles are relaxed. Thedistance has been measured to be 2-4 mm (freeway space orinterocclusal distance). When the resting vertical dimension isaltered, as clinically observed with faulty posture, it encroachesthe freeway space, the mandibular condyle may intrude upwardand backward in glenoid fossa, the teeth may be in contacteliminating the rest position and creating tension on the muscleof mastication and stress on teeth and supporting structures.The tongue is suspended like sling by its myofacial andligamental attachments from the styloid process of the temporalbone and the anterior portion of the mandible. It has beendemonstrated that cervical muscle influences masticatorymuscle activity. The influence of posture and stress onmusculoskeletal pain and dysfunction is a prime etiologic factorthat is commonly overlook. Normal mandibular rest position maybe altered by respiratory, posture, masticatory andtemporomandibular intracapsular disorders.

The forward head posture is commonly associated with atemporomandibular joint dysfunction and the temporomandibularjoint dysfunction is commonly associated with a forward headposture.

Aims and Objective

Observe the effect of deep cervical flexor strengtheningon vertical mandibular opening on subjects with forward headposture. This study is to determine if the correction of forwardhead posture may help to improve the temporomandibularfunction.

Hypothesis

The deep cervical flexor strengthening is effective inimproving forward head posture and also has an effect on verticalmandibular opening.

Methodology

Sample

30 subjects with forward head posture (FHP) participatedin this study, but 3 were lost in follow-up till end.

Only 27 subjects (14 female and 13 male) completed theexercise protocol of one month.

The subjects were recruited from Sushila Tiwari MemorialHospital, Haldwani. The subjects were of mean age 23.15 +2.50 years, mean height 161.85 + 8.60 cm and mean weight55.96 + 9.31 kgs.

Inclusion Criteria

1. Age- 18-30 years.2. Both male and female subjects.3. All subjects having forward head posture (craniovertebral

angle less then 49 degrees.).

Exclusion Criteria

1. Any history of trauma of cervical region.2. History of cervical spine pathology.3. History of dizziness and vertigo.4. Postural abnormalities like scoliosis.5. Torticollis.6. Known medical problems like Rheumatic arthritis,

Ankylosing spondylitis and Tuberculosis of spine, bones orjoints.

7. Painful temporomandibular joint (TMJ).8. Any popping sound or locking of temporomandibular joint.9. Difficulty with functional activities of temporomandibular

joint, like chewing, talking, yawning.10. Recent teeth excision.11. Current teeth pain or teeth infection.12. History of tobacco chewing.13. Mouth splinting.

Study Design

Experimental study.

Instrumentation

1. Digital camera- A digital Nikon camera (Cool pix L10) with5 mega pixel and 3x zoom lenses was used.

2. Tripod camera stand- A Simpex tripod camera stand wasused.

3. Measuring tape.4. Adhesive skin markers- Red color adhesive marker was

used to denote the anatomical landmarks.5. Image-tool software- UTHSCSA image-tool software for

windows version- 3.00 was used.6. Plumb line7. Millimeter ruler- A 15 cm ruler was used.8. Disposable gloves.9. Disinfected liquid- Isopropyl alcohol U.S.P. liquid was used


to remove skin secretions from the site of anatomicallandmarks fixation and to clean the millimeter ruler, beforeand after taking mandibular opening of each subject.

10. Pressure biofeedback- A pressure biofeedback unit(manufactured by Chattanooga group, Inc, Hixson, TN) wasused for exercise performance.

11. Stop watch- A runner 2000 digital stop watch was used.

Protocol

Based on inclusion and exclusion criteria, the subject wererecruited for the study. Each subject was informed about thepurpose of the study and proper instructions were given aboutprocedure. All subjects went through the consent form, prior toparticipation. Anatomical landmarks were marked at C7 andtragus of the ear. Digital photograph was taken for measuringthe craniovertebral angle. After this subject were checked forvertical mandibular opening.

Procedure

All the subject were ask to sit comfortably on back supportedarmless chair with both feet flat on floor, hips and kneespositioned at 900 angle and buttock positioned against the backof chair. The subjects were asked to rest their hands on their lapand to keep their shoulder against the back of the chair. Adequateexposure of neck up to shoulder level to clearly define anatomicallandmarks was done. The most prominent spinous process atthe base of cervical spine was palpated. After it was identified,the cervical spine was passively flexed and extended to verifywhich one moved first. C6 vertebra should be more mobile,whereas C7 should demonstrate less motion. Skin over theanatomical landmarks was wiped with cotton soaked in sprit toremove skin secretions for proper fixation of adhesive markers.Anatomical landmarks were marked with marker pen; thereafteradhesive markers were fixed over the anatomical landmarks.Then taken the measurement of the height between ground andC7 in sitting position of each subject was done with help ofmeasuring tape. That same reading was taken to adjust cameraheight over the tripod. The camera was placed so that the centerof the lens was 0.8 meter from the subject in orthogonal to sagittalplane of the subject.

Distance between chair and tripod was fixed at 0.8 meterand not altered in any conditions.

The craniovertebral angle was measure by angle betweenmid point of the adhesive marker at tragus of right ear and midpoint of the reflective marker at C7. This angle described theposition of head relative to C7 when viewed from right side ofhead relative to C7. Then the photographs were transferred tolaptop for measuring the craniovertebral angle by usingimagetool software.

After that all subjects were asked to sit comfortably on backsupported armless chair with feet flat on floor, hips and kneespositioned at 90 degree angle and hands on their lap. Thesubjects were asked to focus on a point directly in front of themand to open their mouth as widely as possible without feelingany strain. The vertical mandibular opening was measuredbetween the incisal edges of the right upper and lower centralincisors teeth by using a millimeter ruler. The same procedurewas repeated for three times and mean value of the readingsobtained. A pair of sterile hand gloves was worn throughout theprocedure. The subjects were not asked to eat or chew gum forat least one hour before the measurement.

The exercise procedure with pressure biofeedback (cranio-cervical flexor exercise) was explained to the subject. Low loadendurance exercises were used to increase the tonic holdingcapacity of deep neck flexors muscles. In this, subject waspositioned in supine lying. Then pressure biofeedback wasplaced between the plinth and the posterior aspect of the cervicalspine just below the craniocervical junction. The subject’s head

and neck was positioned to ensure a neutral cervical spine andcraniocervical position. The pressure sensor was inflated to 20mm of Hg so that the space can be filled between the back ofthe neck and the plinth. As already instructed, subject placedthe tongue on the roof of the mouth, lip together but teeth justapart, then asked the subject to posterior retraction of chin topush neck directly back on the sensor. Each subject was givensufficient time to practice the same exercise with pressurebiofeedback unit. The dial was kept in front of the subject sothat he can monitor any deflection of the pointer during holdingphase which was 10 second. The feedback which was given bythe pressure sensor showed the subject’s ability to hold theposition in a controlled manner.

Two sets of 10 repetitions were done, with 2 minute rest inbetween. This exercise was given to all the subjects for 5 daysin a week for one month. A home exercise program wasinstructed to all subjects for rest of 2 days of the week. Forhome exercise program the subjects was asked to placed a 4inches towel roll under the neck at place of pressure biofeedbackunit and performer the same procedure of craniocervical flexionexercise.

After 1 month the outcome measures were assessed againfor craniovertebral angle and vertical mandibular opening bysame procedure which was already described.

Data Analysis

Data was analyzed with the SPSS statistical package(version-12). Descriptive statistics (age, height, weight) werecalculated in terms of number of subjects, minimum andmaximum values, mean and standard deviation.

Student’s paired t-test was used to test change inquantitative data preintervention and postintervention i.e.craniovertebral angle and vertical mandibular opening.

Pearson product moment correlation analysis was used tostudy correlation between craniovertebral angle and verticalmandibular opening for all the subjects.

Results

Sample comprised of 27 of subjects recruited in one group.The age of subjects ranged from 19 to 28 years, mean age was23.15 + 2.50 years. The height ranged from 151 to 178 cm,mean height was 161.85 + 8.60 cm. The weight ranged from 40to 85 kg, mean weight was 55.96 + 9.31 kg. (Table-5.1)

The mean value of pre intervention craniovertebral angle(C.V.A.) of the subjects was 45.13 + 11.05 and the mean valueof post intervention craniovertebral angle of the subjects was54.16 + 10.79. The mean value of pre intervention verticalmandibular opening (V.M.O.) of the subjects was 3.49 + 0.24and the mean value of post intervention vertical mandibularopening of the subjects was 2.99 + 0.23. (table-5.2)

Compared with baseline data the mean change incraniovertebral angle, after the 30 days of exercise protocol was-9.03 + 2.47. Subjects with forward head posture demonstrateda significant progressive increase in craniovertebral angle postintervention. (t= -18.95, p<0.001).

Following the 30 day of intervention of the exercise meanchange in vertical mandibular opening was 0.49 (SD=0.09). Allthe subjects in the group showed reduction in vertical mandibularopening from pre-intervention and post-intervention (t=26.31,p<0.001). (table-5.3)

Correlations

The correlation of mean change in craniovertebral anglewith mean change in vertical mandibular opening of the subjectswas found 0.27 which is a poor correlation between the variables.


Table 5.1:

Variables Values (Mean + SD) Minimum Maximum

Age (years) 23.15 + 2.50 19 28

Height (cm) 161.85 + 8.60 151 178

Weight (kg) 55.96 + 9.31 40 85

Table 5.2: Mean value of pre intervention and post intervention C.V.A. and V.M.O.

Preintervention Postintervention

C.V.A. 45.13 + 11.05 54.16 + 10.79

V.M.O. 3.4 + 0.24 2.99 + 0.23

Table 5.3: Comparison of C.V.A. and V.M.O.

Variables Mean difference post intervention t-value p-value

C.V.A. 9.03 + 0.47 -18.95 0.000

V.M.O. 0.49 + 0.09 26.31 0.000

Fig 5.1: Mean value of C.V.A. pre-intervention to post-intervention

Fig 5.2: Mean value of V.M.O. pre-intervention to post-intervention


Fig. 5.3: Correlation of C.V.A. and V.M.O. of between pre-intervention to postintervention

Discussion

The result of the study showed a relationship exists betweenthe strengthening of deep cervical flexors and the verticalmandibular opening. The results showed that strengthening ofdeep cervical flexors cause increase in craniovertebral angleand decrease in vertical mandibular opening. The results of thisstudy also show that there is decrease in vertical mandibularopening after the deep cervical flexors strengthening. This resultalso support the previous researches that the postural trainingaffects the temporomandibular joint. The present study reportedthat there is increased in vertical mandibular opening associatedwith a forward head posture (Craniovertebral angle less then49°) in subject with a normal temporomandibular joint.

The study proved that there was increased in verticalmandibular opening after correction of a forward head posture.The subject of the study was a 48 years old female havingtemporomandibular joint dysfunctions. The result of the studyshowed the relation of stomatognathic system with posture.Some resent study also shows this relationship. The studydocumented that with anterior position of the head alsoinfluences the position of center of gravity and confirm therelationship between the body posture and temporomandibularjoint dysfunctions The results of the present study showed apoor correlation between mean changes in Craniovertebral angleand vertical mandibular opening. This is supported by Darlowet al which showed no correlation between temporomandibularjoint dysfunctions in relation to posture. Some of the subjectsreported to have neck pain preintervention due to poor posturalhabits. They reported neck pain with or without muscle spasmaround upper back after prolong sitting, computer work orstudying. All thesubjects associated with neck pain got relief inpain postintervention.

Forward head posture leads to excessive lengthening withassociated weakness of anterior vertebral neck flexors andtightness of neck extensors. Additional changes includeshortening of suboccipital and suprahyoid musculature andlengthening of infrahyoid muscle with elevation of hyoid bone.There is also isometrical shortening of posterior of posteriorcervical muscles while anterior submandibular muscles arestretched to cause retrusive force on mandibular In erect headposture the initial condoyle rotation occur as mandibularelevators (masseter, temporal and medial pterygoid muscles)gradually relax and allowing gravity to depress themandibular.The excessive mouth opening is also common when jointcapsule is stretched and joint become hypermobile.Temporomandibular joint hypermobility has been postulatedwhen the condyle is excessively passing the articulatingeminence at the translation phase of mandibular opening.

The forward head posture causes intrusion of condyleupward and backward into the glenoid fossa The improved headposition may decrease the stretch of anterior cervical muscleswith a resultant decreased in retruive force on mandible Thusthe result of the present study shows that the strengthening ofdeep cervical flexor causes decrease in retrusive force of

mandible and tension length of anterior neck muscles and furtherit causes decrease in mouth opening.

Conclusion

It is concluded from this study that the strengthening ofdeep cervical neck flexor muscle has an effect on the verticalmandibular opening. This causes a significant decrease in mouthopening on subject having a normal temporomandibular joint.

References

1. Wright EF. A simple questioner and clinical examination tohelp identity possible non-craniomandibular disorder thatmay influence a patient craniomandibular disordersymptom. Cranio 1992, 10, 228-234.

2. Thomas tai WC, Ellis Yuk HL, Tony Hiu FC. Performanceof craniocervical flexion test in subject with and withoutchronic neck pain. JOSPT 2005, 35(9), 567-571.

3. Cuccia Antonino, Caradonna Carola, The relationshipbetween the stomatognathic system and body posture.Clinics, 2009, 64(1) 61-66.

4. McCain GA and Scudds RA. The concept of primaryfibromyalgia: clinical value, relation and significant to otherchronic musculoskeletal pain syndrome. Pain, 1988, 33,273-287.

5. Simons DG, Travell JG. Myofascial pain and dysfunction:the trigger point manual, the upper half of the body.Published by Lippincott Williams and Wilkins. Secondedition.

6. Grace PY, Szetoa B, Leon Strakerb, SallyRaine. A fieldcomparison of neck and shoulder postures in symptomaticand asymptomatic office workers. Applied Ergonomics2000.

7. Falla Deborah, Jull Gwendolen, Russel Trevor, VicenzinoBill, Hodges. Effect of neck exercise on sitting posture inpatient with chronic neck pain. Physical therapy 2007.

8. Santiesteban, Joseph A. Isometric exercise and a simpleapplication for TMJ dysfunction: a case report. Physicaltherapy 1989, 69(6), 463-466

9. Kritsine M, Shim YS. Malocclusion, body posture and TMDin children with primary and mixed dentition. J clin pediatrdent, 16(2), 86-93.

10. Visscher CM. et al, Kinematics of the human mandibularfor different head posture. Journal of oral rehabilitation,2000, 27, 299-305.

11. Agerberg G, Carlsson GE. Symptom of functionaldisturbance of the masticatory system. Acta Odont Scand,1975, 33 183-190.

12. Hesse JR, Naeije M, Hansson TL. Craniomandibularstiffness in myogenous and arthogenous CMD patients,and control subjects: a clinical and experimentalinvestigation. Journal of oral rehabilitation,1996, 23, 379-385.


Effects of Limb Dominance on Cross TrainingDheeraj Lamba1, Heena Maheshwari2, Kavita Kandpal3, Babita Mishra4, Preeti Joshi5

1Incharge, 2,3,4,5Interns, Dept of Physiotherapy, IAHSET Medical College Haldwani

Introduction

Cross education’ or the ‘cross training’ is an inter limbphenomenon first reported by Scripture. The strength trainingof one limb produces increased strength of contra lateralhomologous group. The increase in strength observed withstrength training is due to both hypertrophy and adaptationswithin nervous system. Adaptation to strength training are mostoften specific to movement pattern, velocity, contraction typeand contraction force used during training Improvements instrength training can occur with training with high forcecontractions or even with mental rehearsal of a contralateraltask. Improvement in contralateral muscle strength can alsooccur when muscle contractions are evoked by electricalstimulation. It has hitherto been reported by many authors thatstrength training of one limb causes a significant increase involuntary strength not only in trained limb but also in contralaterallimb. The magnitude of cross education is normally about 25%but in a few cases, force or skill transfer reached 80%. Thehallmarks of these adaptations are that the amount of force orskill transfer is proportional to the gains in the trained muscle.The strength gains in the contra lateral homologous muscle arespecific to the involved muscle pair and are independent of limbdominance, age, gender. However, the physiologicalmechanisms underlying the strength increase in contra laterallimb remain unclear.

Strength is determined not only by quantity and quality ofthe involved musculature but also by the degree to which themuscle mass has been activated. It is well established thatphysical activity that incorporates high muscle tensions, i.e.,heavy resistance strength training, can lead to an increase inmaximal contractile muscle force. However, the specificmechanisms responsible for this adaptation are not fully known.Strength training programmes are commonly used to enhanceperformance, reduce the incidence of overuse injuries, andassist in the rehabilitation of orthopaedic and athletically inducedmusculoskeletal injuries. Side-to-side strength imbalances inthe range of 10% to 15% in other muscle groups have beenassociated with increased injury rates. Knapik et al reportedincreased lower extremity injury rates in female athletesdemonstrating 15% strength deficits of either the left quadricepsor hamstrings muscles. 10% side-to-side strength differential inthe hamstrings was associated with an increased incidence ofhamstring strains. Cross training may have clinical relevancefor prescribing resistance exercise in strength rehabilitation.Many authors have proved that there is more strength indominant limb than non-dominant limb. Ross revealed higherdominant isokinetic knee strength than non-dominant kneestrength in young adult men and women. Burnie and Brodie(1986) determined that isokinetic knee flexion or extensionstrength difference did not exist between the dominant andnondominant leg in preadolescent males. Masuda (2003) foundnegligible differences between the dominant and non-dominantisokinetic leg strength during knee flexion and extension, hipflexion and extension, hip abduction and adduction in universitysoccer players. Neumann (1988) found no difference betweenright and left isometric hip abduction torque across multiple hipangles in young adult men and women. In contrast to thesefindings, Hunter et al (2000) found slightly higher dominant kneeextension isometric torque (128.1 ± 3.0Nm) compared to the

non-dominant leg (122.3 ± 3.0Nm) in 217 women between theages of 20 to 89 years. Comparison of strength betweendominant and non-dominant limb was significantly done by manyauthors. Contralateral training effects have been extensivelyinvestigated because they provide important insights intophysiological determinants of muscle strength. Nonetheless theavailable evidence now clearly indicates that the contralateralstrength training effect is real, not just an experimental artifact.Munn et al conducted a meta analysis of the entire availableliterature and concluded that increased contra lateral limbstrength by 7.8% corresponds to 35% strength gain on ipsilateraltrained side. None of the authors has studied the effect of limbdominance on contralateral strength gain. Therefore, the studywas design to investigate whether limb dominance has any effecton cross training.

Aims and Objective

The purpose of study was to compare, in a randomizedfashion, the effects of limb dominance on cross training.

Hypothesis

Limb dominance will not have any effect on cross training.

Methodology

Sample

Thirty healthy male and female (7 females + 23 males)subjects from Sushila Tiwari Hospital volunteered to participatein the study. All the subjects were right side dominant and weregrouped under two different groups. Each group had 15 subjectseach.

Group A- Subjects included with mean age 24.80±1.52,mean weight 60.13±9.48.

Group B- Subjects included with mean age 24.73±1.03,mean weight 62.26±8.73.

Inclusion Criteria

1. Both male and female subjects included.2. Age 18-28 years.3. Height 150-180cm.4. Weight 55-75 kg.5. BMI 19.5-24.5

Exclusion Criteria

1. History of lower extremity fracture.2. History of knee surgery.3. Presence of any deformity at knee joint.4. Limb length discrepancy.5. Hamstring tightness.6. History of lower extremity muscular strain or ligamentous

sprain.7. Presence of knee instability.8. Presence of any cardiovascular and respiratory problems.

45

Study Design

Experimental study.

Instrumentation

Humac Norm (CSMI/Humac Norm testing and Isokineticrehabilitation system) Humac Norm is used for measuring andimproving human performance in the clinic training room andresearch laboratory.

Protocol

Procedure

30 college students were selected and whole procedurewas explained to the subject on the first day and a consent formwas signed by each subject. Then, they were randomly assignedinto 2 groups. Height and weight of each subject was taken.Blood pressure and heart rate were monitored. To assess thelimb dominance subjects were asked to kick the ball and limbused to kick ball was considered as dominant limb. Subjectswere divided into two groups:

Group A- This group trained the dominant leg only.Group B-This group trained the non-dominant leg only.

Training Procedure

The participants warmed up by running on a treadmill for 5minutes at self selected speed. To localize the contraction toproper muscle groups, the subjects were seated and securelystrapped at the thigh, hip and chest. The axis of dynamometerwas aligned at the pivot of knee joint. A lever was connectedjust above the ankle.

Pre-exercise Testing

Group A- Testing was done on non-dominant limb on firstday of exercise at speed 60º/sec.

Group B- Testing was done on dominant limb on first dayof exercise at speed 60º/sec.

Exercise Protocol

Concentric training to knee flexors and extensors was givento each group. For Group A, dominant limbs were exercisedand for Group B nondominant limbs were exercised. Eachexercise trial consisted of 6 maximal concentric contraction of

knee flexors and extensors for a total of 12 reciprocal contraction.30 sec rest period in between training was given 3 times/ weekfor a period of 2 weeks.

Post-exercise Testing

In each group isokinetic testing was done again after 2weeks training to assess improvement of peak torque on non-trained homologous muscle group.

Data Analysis

The data was analyzed by using SPSS Version 12.0software. Paired sample t-test was done to calculate the peaktorque within the groups.

Independent sample t-test was done to calculate the peaktorque between groups.

The level of significance was set at 0.05.

Results

Paired t-test done to calculate the peak torque for kneeflexors and extensors within groups.

For Group A, mean and standard deviation of pre and postextension peak torque were -27.400 ± 19.204 with p value 0.000.Mean and standard deviation of pre and post flexion peak torquewere -14.066 ± 14.409 with p value 0.002. Statistical analysisshowed significant difference within the group (Table 5.2)

For group B, mean and standard deviation of pre and postextension peak torque were -18.466 ± 8.757 with p value 0.000.Mean and standard deviation of pre and post flexion peak torquewere -9.800 ± 7.321 with p value of 0.000. Statistical analysisshowed significant difference within the group (Table 5.3).

Independent sample t-test done to calculate the peak torquefor flexors and extensors between groups. Mean peak preextension torque for group A was 44.733 ± 22.691 and for groupB was 57.933 ± 23.119. Statistical analysis showed no significantdifference between the groups P=0.126 (>0.05) (Table5.4). Meanpeak post extension peak torque for group A was 72.133 ±22.812 and for group B was 76.400 ± 18.718. Statistical analysisshowed no significant difference between the groups P=0.580(>0.05) (Table 5.4). Mean peak pre flexion torque for group Awas 17.600 ± 10.655 and for

group B was 23.066 ± 14.728. Statistical analysis showedno significant difference between the groups P=0.254 (>0.05)(Table 5.5).

Mean peak post flexion torque for group A was 31.666 ±16.329 and for group B was 32.866 ± 19.988. Statistical analysisshowed no significant difference between the groups P=0.858(>0.05) (Table 5.5).


Table 5.1: Mean and SD of Age and Weight for the subjects of Group A and Group B.

Variable Mean ± Standard deviation

Age Group A Group B

24.80 ± 1.52 24.73 ± 1.03

Weight 60.13 ± 9.48 62.26 ± 8.73

Table 5.2: Comparison of mean and standard deviation Peak Torque of Extensor and Flexor Muscle group within Group A

Variable Mean ± Standard deviation t value p value

Pre and Post -27.400 ± 19.204 -5.526 0.000Extension Peak torque

Pre and post -14.066 ± 14.409 -3.781 0.002 Flexion Peak torque


Table 5.3: Comparison of mean and standard deviation Peak Torque of Extensor and Flexor within Group B


Pre and Post -18.466 ± 8.757 -8.167 0.000Extension Peak torque

Pre and post -9.800 ± 7.321 -5.184 0.000 Flexion Peak torque

Table 5.4: Comparison of mean and standard deviation of Pre and Post Extensor Peak Torque between Group A and B


Pre-test Group A Group B -1.165 0.25417.600±10.655 23.066±14.728

Post-test 31.666±16.329 32.866±19.988 -.180 0.858

Table 5.5: Comparison of mean and standard deviation of Pre and Post Flexor between Group A and B


Pre-test Group A Group B -1.165 0.25417.600±10.655 23.066±14.728

Post-test 31.666±16.329 32.866±19.988 -.180 0.858

Discussion

The purpose of this study was to determine whether thefunctionally dominant and non-dominant legs of healthyindividuals differ on cross training effect. The results of thepresent experiment indicate that the limb dominance does nothave an effect on cross-training, thereby supporting thehypothesis. There is also evidence that the strength trainingprogram improved peak torque of the trained leg as well as theuntrained leg in the subjects who participated in the strengthtraining program. The results of this study are in agreementwith the majority of previous research that reveals no differencein peak torque between the dominant and non-dominant limbs.Holmes and Alderink, 1984 revealed no difference in isokineticstrength of the quadriceps femoris and hamstring muscles inhigh school-aged students between dominant and non-dominantlimbs. Similar results were found in isokinetic plantar flexionstrength. Wei-Hsiu (2009) found no significant difference inunilateral ankle internal/external rotation and static balancecontrol in the dominant and non-dominant limbs in young, healthyadults. B.D. Beynnon found no significant difference in single-leg strength training program for the muscles around theuntrained ankle between dominant and non-dominant legs. It islikely that peak torque responds more quickly to strength trainingas compare to power and endurance. Similar studies have alsobeen conducted on athletes in an open kinetic chain test.Masuda assessed isokinetic hip and knee strength and revealedthat no difference between dominant and non-dominant leg inelite soccer player. Agre and Baxter (1987) and Ostenberg (1998)also found no difference in isokinetic knee extensor strengthbetween dominant and nondominant leg in men and womensoccer players. In a recent study, Magalhaes did not find asignificant difference in isokinetic knee extensor strengthbetween the dominant and non-dominant leg in elite volleyballand professional soccer players.

The results of the present experiment may be explained byPrevic’s neurodevelopmental theory, explained for footdominance in the unilateral and bilateral context. According tothis theory, the idea that there is no clearly dominant limb inbilateral context seems reasonable, that is, one foot providesnecessary postural support while the other executes voluntary(mobilizing) action as the complementary role action. K McCurdy

and G Langford revealed that the strength, measured in a weightbearing stance, is similar between the dominant and non-dominant leg in young adult men and women who participate ingeneral activities of daily living and are untrained in unilateralexercises. The results of the present study indicate that the peaktorque measured between dominant and non-dominant leg inyoung adult men and women have no significant difference inindividuals who participate in general activities of daily living.Kramer and Baslow 1990 revealed significantly higher 7% kneetorque in dominant leg for intercollegiate soccer players andsuggested that the difference in the volume of activity betweenthe dominant and non-dominant leg could produce side-to-sideimbalance. Imbalance between limbs is also thought to be relatedto an increase risk of injury. (Agre and Baxter, 1987). Thus theresults of the study are in agreement with Previc’s neurodevelopmental theory and the fact that subjects in this studywere non athletes as could also be a factor explained by KMcCurdy and G Langford. These findings are particularly helpfulto the clinician who uses singlelegbalance testing in theevaluation and rehabilitation of lower limb injuries. Whenasymmetry is present in single-leg balance testing, it is a functionof acute or chronic injury and not due to functional leg dominance.Based on the results of present study, it can be said that limbdominance does not have an effect on peak torque gained inuntrained limb (cross training), for young adult men and womenwho participate in general activities of daily living.

Conclusion

It can be concluded from the present study that there is nosignificant difference in effect of cross training between thedominant and non-dominant leg for non-athletes.

References

1. Haddon G.B., Speakman (1975) A study of cross-educationin strength Australian J of Physiotherapy 21(1):24-26

2. Brital et al (1974) Blood flow in resting (contralateral) armand leg during isometric contraction J Physiology 240: 111-124

3. Young et al (2003) Excitability of the ipsilateral motor cortexduring phasic voluntray hand movement. J ExperimentalBrain Research 148:176-185


4. Liopert et al (2001) Inhibition of ipsilateral motor cortexduring phasic generation of low force. J ClinicalNeurophysiology 112: 114-121

5. Wolf et al (2001) Role of the human motor cortex in rapidmotor learning. J Experimantal Brain Research. 136: 431-438

6. Luis A.T., Leandro Q.C.(2003) Intermanual transfer of forcecontrol is modulated by asymmetry of muscular strength JExperimental Brain Research 149: 312-319

7. Trimothy et al (2001) Neural adaptations to resistancetraining: Implications for movement control J SportsMedicine 31(12): 829-840

8. Trimothy et al (2002) The sites of neural adaptaion inducedby resistance training in humans J of Physiology 544 (2):641-652

9. R.G. Carson (2005) Neural pathways mediating bilateralinteractions between the upper limbs. J Brain ResearchReviews 49:641-662

10. Heydar et al (2000) Symmetry and limb dominance in able-bodied gait: A review Gait and Posture 12:34-45

11. Michael P (1980) The development of mature gait J Boneand Joint Surgery 62: 336-353

12. Vickie G, Carl G (2001) Foot-preference behavior: Adevelopmental perspective. J of General Psychology122(1): 37-45

13. Sutherland et al (1980): The developmental of mature gaitJ Bone and Joint Surgery 62: 336-353

14. B.S. Pande, Inderbir Singh (1971) One-sided dominancein the upper limbs of human fetuses as evidence byasymmetry in muscle and bone weight J Anatomy. 109:457-459

15. Fred H. Previc (1991) General theory concerning theprenatal origins of cerebral laterization in humans Jpsychological Review 98(3) 299- 334

16. Rita et al (1984) Development of motor co ordination bynormal lefthanded children J Developmental Medicine andChild Neurology 26:104-111

17. Megan A, Dawne L.(1993) Laterality, motor asymmetry andclumsiness in children J Human Movement Science 12:115-177

18. Robert W, Anderson (1992) Test-retest reliability ofreciprocal isokinetic knee extension and flexion peak torquemeasurements J of Athletic Training 27(4): 362-365

19. Denise et al (2000) Effects of isokinetic strength trainingon concentric and eccentric torque developmental in theankle dorsiflexors of older adults J of Gerontology55(10);465-472

20. Karnofel et al (1989) Reliability of isokinetic muscle testingat the ankle. J of Orthopaedic and Sports Physical Therapy11(4): 150-154

21. Richard et al (1986) Isokinetic knee flexion and extensiontorque in the upright sitting and semireclined sittingpositions. J of Physical Therapy 66(7): 1083-1086.

48 Gagandeep Kaur / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Relationship Between Motor Impairments of Hand and ManualAbility in Spastic Cerebral Palsy ChildrenGagandeep Kaur1, Poonam Mehta2, Chandan Kumar3

1Student, 2,3Lecturer, M M IPR, M M University, Mullana, Ambala, Haryana, India

Abstract

Introduction

Cerebral palsy is a static neurologic condition resultingfrom brain injury that occurs before cerebral developmentincomplete. Hand impairments are related to the manual ability.Hand impairments are not rare in the cerebral palsy but theyare not considered significantly. We assessed the handimpairments in relation to manual ability amongst Cerebral palsychildren who were spastic diplegics and quadriplegics.

Material and Methods

Thirty cerebral palsy children were assessed. Handimpairments included grip strength, fine finger dexterity, grossmanual dexterity and these were assessed by hydraulic handhandle dynamometer, pegboards and box and block testrespectively. Manual ability was assessed by

Abilhand kid’s questionnaire. All the subjects according tothe inclusion criteria were included in the study. One timeassessment was taken. For the grip strength and fine fingerdexterity three readings were taken and average of these threereadings was taken as the final score. For box and block testsingle reading was taken. Spasticity was assessed by theModified Ashworth Scale. Results were calculated by usingPearson’s correlation.

Results

There is a significant correlation between grip strength,fine finger dexterity, gross manual dexterity and manual ability.Grip strength has correlation of -0.459(P=<0.05) with the manualability, fine finger dexterity has the correlation of -.732(P=<0.05)with the manual ability and gross manual dexterity has thecorrelation of -0.781(P=<0.05) with the manual ability.

Key Words

Cerebral palsy, impairments, manual ability.

Introduction

Cerebral palsy is an umbrella term encompassing a groupof non progressive, non contagious motor condition that causesphysical disability in human development, chiefly in various areasof body1.Martin Bax defined “Cerebral palsy as a disorder ofposture and movement that occurs secondary to damage to theimmature brain before, during or after birth. This disorder is calleda static encephalopathy because it represents a problem withbrain structure and function2.The birth prevalence of cerebralpalsy ranged from 1.18 to1.97 per 1000 live birth each year,with a mean of 1.51 per 1000 live births3.

Address for correspondence:Gagandeep KaurM.P.T. Pediatrics StudentContact number+91-09896429194.E-Mail: [email protected]

Cerebral palsy is a static neurologic condition resulting frombrain injury that occurs before cerebral development incomplete.Because brain development continues during the first two yearsof life, cerebral palsy can result from brain injury occurring duringthe prenatal, perinatal or post natal periods. Etiology of cerebralpalsy include problems in intrauterine development (e.g.exposure to radiation, infection),asphyxia before birth, hypoxiaof the brain and birth trauma during labor and delivery,complications in the perinatal period or duringchildhood1.Braindevelopment continues during the first two years of life, cerebralpalsy can result from brain injury occurring during the prenatal,perinatal or post natal periods4.

According to tone classification includes spastic, athetoidi.e. hypotonic/floppy or atonic. Spastic type of cerebral palsy isthe commonest type. Spastic Cerebral palsy associated withdamage to cortical motor areas and underlying white matter,choreoathetotic cerebral palsy associated with damage to basalganglia, ataxic cerebral palsy is associated with damage tocerebellar structures7 Spastic cerebral palsy consists of hypertonicity of clasp-knife variety, abnormal postures, weakness ininitiation of motion. Changes in hypertonous and posture mayoccur with excitement, fear or anxiety. Intelligence is impairedthan athetoid Impairments include motor impairments andsensory impairments. Motor impairments include abnormalreflexes, disturbances in balance, locomotion, propulsion ofobjects and sensory impairments include tactile pressurestereognosis, proprioception4, cerebral palsy. Perceptualproblems, sensory loss, epilepsies, poor ribcage abnormalitiesand poor respiration4,5.

The aim of physiotherapy is to make patient maximumindependent. Physical therapy includes muscle strengtheningand fitness programs as popular interventions for cerebral palsy;however advocates of neuro developmental treatment adviseagainst the use of resistive exercises because it is believed toincrease spasticity18.It is also shown that resistive exercise couldbe beneficial in strengthening when muscle weakness causesdysfunction19. Stretching exercises, sensory stimulation, PNF,Biofeedback are also used4,5. Orthotic devices such as anklefoot orthosis are often prescribed to minimize gait irregularities20.AFO’s have been found to improve several measures ofambulation, including reducing energy expenditure andincreasing speed and stride length20.21.

Previous studies show that hand impairments and manualability are correlated to each other. In previous studies, gripstrength was measured by Jamar dynamometer, gross manualdexterity was measured by box and block test, fine fingerdexterity was measured by Purdue pegboard. But in presentstudy, the grip strength is measured by Hydraulic hand handledynamometer which measures the strength in kgs, gross manualdexterity is measured by box and block test, in which one woodenbox is there having six inches partition in it with 150 blocks ofone inch and fine finger dexterity is measured by pegboards(square pegboard and fine finger test).The square pegboard istwelve inches in length and twelve inches in width. It consists of25 pegs and 25 holes. The fine finger dexterity test consists of

49

two square wooden boards, one is having 49 holes in it andother is having one cup which consists of 49 pins in it and oneforcep in it.

Manual ability is a major component of daily living activities.Hand impairments are related to the manual ability. Handimpairments are not rare in the cerebral palsy but they are notconsidered significantly. There are very few studies done toassess the hand impairments and to measure the manual ability.Because there is lack of instrumentation to assess theseimpairment and manual ability. This study will help to measurethe hand impairments and manual ability. And will also help tofind the relation between these impairment and manual ability.

The objective of this study is to find the relationship betweenhand impairments (Grip strength, gross manual dexterity andmanual ability) and manual ability in children with spastic cerebralpalsy (diplegics and quadriplegics).

Objective of the Study

To evaluate hand impairments i.e. grip strength, fine fingerdexterity and gross manual dexterity in relation to manual ability.

Hypothesis

Alternate Hypothesis

There is a significant correlation between hand impairmentsand manual ability.

Null Hypothesis

There is no significant correlation between handimpairments and manual ability.

Methodology

This chapter contains cerebral palsy children’s handimpairments and their relation with the manual ability.

Study Design

Correlation.

Sample Size

A convenience sample of total 30 subjects with alreadydiagnosed cerebral palsy were included in the study.

Study Population

Subjects were taken from the M.M.I.P.R Mullana and M.M.Hospital Mullana.

Inclusion Criteria

Children who fulfilled the following criteria were taken intothe study.1. Children diagnosed with cerebral palsy (Diplegics and

Quadriplegics).2. Age between 5-13y (Both boys and girls).3. Children with no major intellectual deficits.

Exclusion Criteria

1. Children with learning disabilities.2. Children undergone surgical procedures (for upper limb)3. Children with major intellectual deficits.

Outcome Measures

In the study the following outcome measures were taken.1. Abilhand kids questionnaire.2. Grip strength.3. Gross manual dexterity.4. Fine finger dexterity

Instrumentation

Following instruments were used in the study.1. Hydraulic Hand Handle Dynamometer.2. Box and Block Test.3. Pegboard Test.

Procedure

30 subjects were selected on the basis of inclusion criteria.A thorough assessment was done. The procedure of the studywas explained to parents/guardian and written consent wastaken. The children were tested individually and instructions thathow to perform each test were given to them. Three motorimpairments i.e. Grip strength, Gross manual dexterity and finefinger dexterity were assessed on both hands, starting withdominant hand. Handedness was determined by writing handpreference. Grip strength was measured with Hydraulic Handhandle dynamometer. The grip strength score was determinedas the average of maximum force exerted on dynamometeracross three trials. According to standard position for testingwhich was recommended by American Society of Hand therapist,the readings were taken. The child sat in a straight backed chair,feet flat on the floor ,shoulders adducted in a neutral, armsunsupported, elbows flexed at 900,forearm rotation neutral, wrist0-300dorsiflexion and 0-150 ulnar deviation. Gross manualdexterity was measured by Box and Block test. The child satstraight on the chair and box was kept in front of the child andinstructions were given to him that how to perform the test. Thescore was determined as the maximum number of blockstransported from one compartment to another in one minute.Fine finger dexterity was measured by the pegboard test. Thechild sat on the chair and pegboard was kept in front of the childand instructions how to perform the test were given to him. Thechild was instructed to do 2 times practice before performingthe final test. The fine finger dexterity score was determined bythe number of pegs picked up from a cup and placed into holesof a board in one minute. Manual ability was assessed byAbilhand kids questionnaire. This questionnaire measures thechild’s capacity to manage daily activities requiring the use ofhand and upper limb. Twenty one mostly bimanual activitieswere rated by children’s parents on a 3-level scale (0-impossible,1-difficult, 2-easy) by providing their child’s perceived difficultyin performing each activity.

Data Analysis

A Pearson correlation coefficient was calculated to examinethe relationship between grip strength, fine finger dexterity, grossmanual dexterity and manual ability. P value was set at<.05.SPSS version statistical software was used for analysis.

Results

All (30) subjects meeting inclusion criteria were invited toparticipate in the study. All 30 subjects consented and completedall observation. Subjects included were both boys and girls.Subjects included in the study were diplegics and quadriplegics.All the subjects include in the study were of age between 5-13y. Subjects were taken from out patients departments.

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50 Gagandeep Kaur / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Table 1: Mean and standard deviation of grip strength, fine finger dexterity, gross manual dexterity and manual ability.

Mean for RT grip strength is 2.303 ± 0.712 and for LT gripstrength is 1.913 ± 0.224.

Mean for RT fine finger dexterity is 12.777 ± 1.926 and forLT fine finger dexterity is 10.000 ± 2.777.

Mean for RT gross manual dexterity is 22.867 ± 3.711 andfor LT gross manual dexterity is 16.933 ± 2.852

Mean for manual ability is 27.833 ± 8.073.

GRIP FINE FINGER GROSS MANUAL MANUAL ABILITYSTRENGTH DEXTERITY DEXTERITY

RT LT RT LT RT LTMEAN 2.303 1.913 12.777 10.000 22.867 16.933 27.833

S.D 0.712 0.224 1.926 2.777 3.711 2.852 8.073

Table 2: Correlation for grip strength, fine finger dexterity, gross manual dexterity with manual ability (Lf & Rt).

The correlation is significant with p value <0.05Correlation with manual ability for grip strength is -0.407(RT)

& -0.567(LT).Correlation with manual ability for fine finger dexterity is -

0.728(RT) & -0.567(LT).Correlation with manual ability for gross manual dexterity

is -0.766(RT) & -0.773(LT).Correlation of grip strength with manual ability is -0.459.Correlation of fine finger dexterity with manual ability is -

0.732.Correlation of gross manual dexterity with manual ability is

-0.781.

GRIP FINE FINGER GROSS MANUALSTRENGTH DEXTERITY DEXTERITY

RT LT RT LT RT LT

Correlationwith manual -0.407 -0.567 -0.728 -0.567 -0.766 -0.773 ability

Table 3: Correlation for grip strength, fine finger dexterity, gross manual dexterity with manual ability.

GRIP FINE FINGER GROSS MANUAL Correlation STRENGTH DEXTERITY DEXTERITY

with manual ability -0.459 -0.732 -0.781

Fig. 1: Correlation b/w grip strength (Rt) and manual ability.

Fig 2: Correlation b/w grip strength (Lf) and manual ability.

Fig. 3: Correlation b/w fine finger dexterity (Rt) and manualability

Fig. 4: Correlation b/w fine finger dexterity (Lf) and manualability

51Gagandeep Kaur / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Fig. 5: Correlation B/W gross manual dexterity (Rt) and manualability

Fig. 6: Correlation B/W gross manual dexterity (Lf) and manualability

Discussion

This chapter deals with the results of the study. In this study,results showed that there is a significant relationship betweenthe hand impairments and manual ability. We found that handimpairments has significant correlation with manual ability. Gripstrength has significant relationship with manual ability whenmeasured with hydraulic hand handle dynamometer andAbilhand kid’s questionnaire respectively. Correlation of gripstrength with manual ability is -0.459.There was a significantrelationship between fine finger dexterity and manual ability whenmeasured with pegboards and Abilhand kid’s questionnairerespectively. Correlation of fine finger dexterity with manual abilityis -0.732. There was a significant relationship between grossmanual dexterity and manual ability when measured with boxand block tests and kid’s questionnaire. Correlation of grossmanual dexterity with manual ability is -0.781.

Results of our study show that the capacity of upper limband completion of ADL’s of upper limb had a significantcorrelation. A study done by Carlyne Arnould et al suggestedthat manual ability was significantly correlated with motorimpairment and stereognosis, while no significant relationshipwas found with tactile pressure detection and proprioception.Melanie Ziebell et al suggested that the children with diplegiaperformed at lower levels in all gross and fine motor assessmentsas compared to children without diplegia.

Massimo Penta et al concluded that grip strength, dexterity,motricity, depression were significantly correlated with Abilhandmeasures which was used to measure manual ability in thestroke patients. Gonca Bumin et al showed that there wassignificant correlation between handwriting parameters andupper extremity speed and dexterity, propioception. bilateralcoordination, visual and spatial perception and visual motororganisation in children with cerebral palsy. Julie Duquesuggested that there is a correlation between impaired dexterityand corticospinal tract dysgenesis in congenital hemiplegiabetween .Jetty Van Meeteren et al suggested that correlationsbetween grip strength parameters and activity limitations wererelatively weak.

Our study suggests that impaired grip strength, fine fingerdexterity and gross manual dexterity, interfere with the activitiesof daily living i.e. manual ability and quality of life. This studyalso suggests that the effect of maturation and hand dominanceand gender is also there. Age and hand dominance and genderalso affects the grip strength, five finger dexterity, gross manualdexterity and so as manual ability. Both impairment and upperlimb activity i.e. manual ability showed a correlation and influenceon activities of daily living.

Clinical Implications

Hand impairments i.e. grip strength, fine finger dexterity

and gross manual dexterity were rarely correlated with manualability. Therefore our study suggests that the other parametersof upper limb are also important to stress upon. So, thisknowledge can assist clinician in making specific treatmentinterventions for improving condition of cerebral palsy children.

Future Research

1. The study can be conducted with a heterogeneous genderbias (either males or females).

2. Subjects included were only spastic diplegic andquadriplegics. The study can be done on any type ofcerebral palsy.

Limitations of the Study

1. Small sample size.2. No gender differentiation.3. Subjects with age group 5-13y.4. Influence of external factors.

Conclusion

There is a significant correlation between the grip strength,fine finger dexterity, gross manual dexterity and manual ability.

Bibliography

1. Kesler Martin Neurological Caonditions 1st Edition,page345.

2. Beukelman et al. Augmentative and AlternativeCommunication: Management of Severe communicationdisorders in children and adults. Baltimore: Paul H BrookersPublishing Co.1999;2:246-2494.

3. P.O. Pharoah et al Trends in birth prevalence of cerebralpalsy. Arch Dis Child.1987 April;62(4):379-384

4. Bass N.Cerebral palsy and neurodegenerative disease CurrOpin Pediatr 1999; 11: 4-7.

5. Sophie Levitt : Treatment of Cerbral palsy and motordelay.3rd Edition,Page 3-12.

6. Ann Thomson et al. Tidy’s Physiotherapy. Twelth EditionPage 361- 366.

7. Joans MW et al.Cerebral palsy:Introduction andDiagnosis(part 1).J Pediatr Health Care. May-June2007;21(3):146-52.

8. Paul D.Cheney.Pathophysiology of the corticospinal systemand basal ganglia in cerebral palsy1998 Dec,volume 3 Issue2.Pages 153-167.

9. Palisano R et al.Development and reliability of a system toclassify gross motor function in children with cerebral palsy.Dev Med Child Neurol.1997; 39: 214-23.

10. Bohannon RW, Smith MB. Interrater reliability of a modified

52

Asworth Scale of muscle spasticity Phy Ther. 1987;67:206.11. Palisano RJ et al. Validation of model of gross motor

function for children with cerebral palsy.Phys Ther2000;80:974-85.

12. Falio M et al.Peabody Development Motor Scales,2nd

Edition examiner Manual,Austin, TX Pro-ED,Inc,200013. Falio M et al.Peabody Development Motor Scales, 2nd

Edition examiner Manual,Austin, TX Pro- ED,Inc,200014. Felters et al.” Discriminate Power of the Alberta Infant Motor

Scale and the movement Assessment of Infants forPrediction of Peabody Gross Motor Scale Scores of InfantsExposed in Utero to Cocaine.”Pediatric Physical Therapy12,no.1(spring 2000):16-23.

15. Mayer NH et al.Common patterns of clinical motordysfunction.Muscle Nerve Suppl.1997;20:S 21-35.

16. Haultram J et al.Botulinum toxin type A in management ofequinus in children with cerebral palsy:an evidence basedeconomic evaluation.Euro J Neurol.2001;8 Suppl 5: S194202.

17. Butler C,Campbell S,for the AACPDM Treatment OutcomesCommittee Review Panel. Evidence of the effects ofintrathecal baclofen for spastic and dystonic cerebral palsy.Dev Med Child Neurol.2000;42:634-45.

18. V.A.Fassano et al.Surgical Treatment of spasticity incerebral palsy.Childs Brain 1978;4:289-305.

19. Mclaughlin J,et al.Selective dorsal rhizotomy:Meta Analysisof three randomised controlled Trials.Dev Med ChildNeurol.2002;44:17-25.

20. Fowler EG et al.The effect of quadriceps femoris musclestrengthening exs.on spasticity in children with cerbralpalsy.Phys Ther.2001;81:1215-23.

21. Dodd KJ et al. A syatematic review of the effectiveness ofstrength training programs for people with cerebralpalsy.Arch Phys Med Rehabil.2002;83:1157-64.

22. Balaban B et al.”The effect of hinged ankle foot orthosis ongait and energy expenditure in hemiplegic cerebralpalsy”.Disability and rehabilitation 29(2):139-44.

23. White H et al.”Clinically prescribed orthoses demonstratean increase in velocity of gait in children with cerebralpalsy”:a retrospective study”. Develpomental medicine andchild Neurology 44(4):227-32.

24. Uvebrant P.Hemiplegic cerebral palsy. Aetiology andoutcome.Acta Paediatr Scand Suppl 1988;345:1-100.

25. Carlyne Arnould et al.Hand Impairments and theirrelationship with manual ability in children with cerebralpalsy.J.Rehabil Med 2007;39:708-714.

26. Fedrizzi E et al.Hand function in children with hemiplegiccerebral palsy:Prospective follow up and functional outcomein adolescence.Dev Med Child Neurol 2003;45:85-91.

27. Ostensjo S et al.Everyday functioning in children withcerebral palsy:functional skill, caregiver assistance andmodifications of the environment. Dev Med Child Neurol2003;45:603-612.

28. Arnould C et al.ABILHAND-Kids:a measure of manualability in children with cerebral palsy. Neurology2004;63:1045-1052.

29. Pagliano E et al.Evolution of upper limb function in childrenwith congenital hemiplegia.Neurol Sci 2001;22:371-375.

30. Penta M et al The ABILHAND questionnaire as a measureof manual ability in chronic stroke patients. Rasch-basedvalidation and relationship to upper limb impairementsstroke 2001;32:1627-1634.

31. Brown JK et al A neurological study of hand function ofhemiplegic children.Dev Med Child Neurol 1987;29:287-304.

32. Krumlinde-Sundholm L,Eliasson A-C.Comparing tests oftactile sensibility:aspects relevant to testing children withspastic hemiplegia.Dev Med Neurol 2002;44:604-612.

33. Julie Duque et al.Correlation between impaired dexterityand corticospinal tracts dysgenesis in congenitalhemiplegia.Brain March 2003 Vol.126,No.3,732-747.

34. Tiffin J.Asher EJ.The purdue Pegboard:norms and studiesof reliability and validity.J Appl Psychol 1948;32:234-247.

35. Mathiowetz V et al.Adult norms for Box and Block Test ofmanual dexterity.Am J Occup

Ther 1985;39:386-391.36. Gonca Bumin and Sermin Tukel Kavak “An investigation of

the factors affecting handwriting performance in childrenwith hemiplegic cerebral palsy.Disability & rehabilitation2008 Vol 30,No.18;1374-1385.

37. Massimo Penta et al “The Abilhand Questionnaire as ameasure of manual ability in chronic stroke patients“.American Heart Association 2001,Vol 32 :1627.

38. Blank R & Hermsdorfer J.”Basic motor capacity in relationto object manipulation and general manual ability in youngchildren with spastic cerebral palsy”.NeurosciLett.2009:23,450(1):65-69.

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53U Ganapathy Sankar / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Discriminant Ability of Gravitational Insecurity (GI) AssessmentU Ganapathy Sankar1, A Prema2

1Vice Principal, SRM College of Occupational Therapy, 2Professor,Department of Pediatrics, SRM Medical College & Hospital, SRMNagar, Kattankulathur-603 203, Kancheepuram, Tamil Nadu

Abstract

Objective

This study examined the reliability and validity of theGravitational Insecurity (GI) Assessment (Revised Version)among Indian children.

Method

The GI Assessment consists of nine items rated on twobehavioral categories - Emotional Responses (ER) and PosturalResponses (PR). Participants were 28 children with GI, 5-10years of age, and a matched group of typically developingchildren.

Results

Discriminant analysis results found that both the behavioralcategories (F(1, 54)=1346.09, ë =0.039;F(1, 54)=357.89, ë=0.131) and all the nine items correctly classified the two groupsat 100% level. A stepwise discriminant analysis revealed thatthe Emotional Response category classified GI children at 96.4%and the Postural Response category classified GI children at100% from typically developing children

Conclusion

The GI assessment is a reliable and valid measure foridentifying children with Gravitational Insecurity. It can be usedas assessment tool as well as outcome measure to find outeffectiveness of intervention program.

Key Words

Gravitational Insecurity,Reliability.

Introduction

Gravitational Insecurity (GI) is described as an abnormalanxiety caused by dysfunction in the integration of sensationthat arises when the vestibular system is stimulated by headposition or movement1. A child with gravitational insecurityoverreacts with a fight or flight response. The fight responsemay manifest as negative or defiant behaviour, particularly whenthe child is passively moved. The child may resist being pickedup, rocked, or pushed in a stroller or may become angry andstubborn when someone suggests riding in the car or slidingdown a hill. Flight responses may be observed as extremecaution or avoidance of movement. The child may keep herhead up and feet down, firmly planted on the ground. The GIchild may avoid riding a bicycle, sliding and swinging2.

Identification of gravitational insecurity has been based ona subjective process involving informal assessment and clinicalobservation of behaviors reflecting symptoms of the disorder.Lee conducted a domain specification study as the first step inthe development of an attitude scale to identify children withgravitational insecurity3. May- Benson4developed an objective

15 item assessment of gravitational insecurity in children. Inthe planning phase of GI tool development, Benson & Koomarconstructed the operational definition and characteristics ofGravitational insecurity, based on literature review1,3,5, survey ofa panel of master occupational therapist experienced in workingwith children having sensory integrative dysfunction. In itemconstruction phase, Item format and scoring criteria weredeveloped through literature review, feedback from expert inthe field of occupational therapy, and clinical observation ofchildren with suspected gravitational insecurity, resulting in 15items and 3 behavioral categories.In quantitative evaluationphase,GI assessment was administered on 18 children with GIand Typically Developing Children(TDC). TDC were matchedby age, gender with GI children. The assessment was revisedto 9 items with 2 behaviour categories based on this studyresults. Interrater reliability (ICC) was .959. The discriminantability of Gravitational Insecurity assessment was notdetermined. Hence, the current study was carried out to identifydiscriminant ability of GI assessment for strengthen thepsychometric properties of GI

Method

Participants

Two groups of children ages 5 to 10 years were included.The first group (n=28; M=6.74, SD = 0.61) consisted of childrenidentified by experienced pediatric occupational therapists ashaving sensory processing dysfunction with gravitationalinsecurity based on behaviors observed during clinicalobservations and ongoing treatment sessions. Children in thisgroup additionally met the following criteria: average intelligence,no physical handicaps, normal (or) corrected hearing, normal(or) corrected vision, or presence of sensory processingdysfunction determined by experience pediatric occupationaltherapist. All children in this group were receiving directoccupational therapy services with a sensory integrativeintervention emphasis and were receiving educationalremediation.

The second group consisted of typically developing children(n=28; M=6.74, sd = .61). who were recruited from mainstreamschools. These children met the following criteria: averageintelligence, no history of physical handicaps, children with goodEnglish comprehension skills, no language problems, no historyof educational remediation, normal hearing, normal or correctedvision, no past or present occupational or physical therapyservices based on parent and teacher reports, and no behaviorscharacteristic of gravitational insecurity.

Instruments

Gravitational Insecurity Assessment (RevisedVersion)

Benson & Koomar developed GI assessment, is anindividually administering test. Administration time is about 10minutes. ICC was .959 4. It has a 3 scoring system with two

behavioral categories. Behavioral categories include EmotionalResponses and Postural Responses. The point scoring is: 3 -Typical response, 2 - Moderate / Mild GI, and 1 - Definite GI.The nine items of the assessment are listed in Table 1. The GIAssessment required the following materials: the GI Assessmentmanual, scoring sheets, pencil, floor mat, standard 100cm meter/ yard stick, standard gymnastic ball (65cm), standard hard seatadult chair with seat height 40-45cm, 45 x 45 x 6cm tilt board,and masking tape.

Procedures

Experienced pediatric occupational therapists in Chennai,were contacted, oriented to the nature of study, and requestedto identify possible children with gravitational insecurity. Thepurpose of the study was then explained to the appropriateauthorities of the special schools and therapy centers involvedand informed consent form was obtained from parents. Testingwas conducted at therapy centers or special schools in Chennai,India. Typically developing children, selected from mainstreamschools in Chennai, were matched by age and gender. Informedconsent was obtained and testing was conducted at the schoolin the same manner as with gravitational insecurity children.

The evaluation was conducted in the standardized formataccording to the protocol developed for the GI Assessment byMay-Benson. All subjects were oriented to the tasks. Thedirections were given in English language for each task andchildren were requested to complete the tasks two times. Twenty

eight gravitational insecurity children and matched typicallydeveloping children were tested by investigator for determinediscriminant ability of GI assessment.

Data analysis

For internal consistency, Cronbach’s alpha was used toevaluate the homogeneity of the test items. Discriminant analysiswas used to identify which behavioral response category andwhich test items were able to discriminate children withgravitational insecurity from typically developing children. SPSS16.0 version was used to analyze that data.

Results

Discriminant analysis results found that both the behavioralcategories (F(1, 54)=1346.09, ë =0.039;F(1, 54)=357.89, ë=0.131) and all the nine items correctly classified the two groupsat 100% level. A stepwise discriminant analysis revealed thatthe Emotional Response category classified GI children at 96.4%and the Postural Response category classified GI children at100% from typically developing children. Further, it revealedthat 4 items (jumping off chair with eye closed, forward roll, tiltboard step and supine on ball – passive) were better able todiscriminate between groups (ë = 19.29) than the other five items(ë = 14.79) (jumping, height jump, stand on chair, backward rolland supine on ball – active). Review of the individual subjectclassification revealed that the one subject was misclassifiedusing the total score of emotional response.

Table1: Test items of Gravitational Insecurity Assessment

Item No Items Description

1 Jumping Participant jumps up and down with feet together

2 Height Jump Participant jumps over a stick raised to 10 cms (4 inches) offground

3 Stand on Chair Participant step up on seat of chair

4 Jump off Chair – Participant hops off chair with eyes closedeyes closed

5 Forward Roll Participant does a forward somersault.

6 Backward Roll Participant does a backward somersault.

7 Tilt Board Step Participant steps on tilt board, then steps off backward.

8 Supine on ball - active Participant lies back on ball, then stands up

9 Supine on ball - Passive Participant lies supine on ball as rater quickly tips it backward.

Discussion

The GI Assessment had excellent discriminant ability. Theemotional response and postural response behavioral categoriesand all nine items were able to discriminate correctly among thetwo groups at 100% level. Further, stepwise discriminant analysisfound that the Emotional Response category alone correctlyclassified 96.4% of GI children and the Postural Response categoryalone classified 100% of the children. While four items were foundto be sufficient to classify groups, correct classification ofparticipants was improved when nine tasks were used instead ofjust four.This study has the limitation of a small sample size andrelatively narrow age range.

U Ganapathy Sankar / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Conclusion

Discriminant analysis is revealed that two behavioralcategory and nine items were necessary to correctly discriminateand classify the two groups. Majority of gravitational insecuritychildren had received occupational therapy services for varyingperiod of time prior to testing. The ability of this tool todiscriminate between groups when the gravitationally insecuregroup has minimal dysfunction is its strength. Finally, resultsrevealed that GI assessment is a reliable measure to identifyingchildren with gravitational insecurity and it can be used asassessment tool.

References

1. Ayres, A. J. Sensory integration and the child. LosAngeles:Western Psychological Services,1979.

2. Kranowitz, C.S. How to tell if your child has a problem withthe Vestibular sense. The out- of – sync child (first ed.,pp104-105),1998. New York: Skylight Press.

3. Lee, L. Domain specification of gravitational insecurity forschool aged children,1987.Unpublished masters’s thesis,Boston Uiversity.

4. May – Benson, T. A, Koomar,J.A. Identifying gravitationalinsecurity in children: A pilot study. American Journal ofOccupational Therapy, 2007, 61, 142 – 148.

U Ganapathy Sankar / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

5. Fisher, A., & Bundy,A. Vestibular stimulation in the treatmentof postural and related disorders. In O.D.Payton, R.P.DiFabio, S.V. Paris,E.J. Protas, & A.F. Van Sant(Eds.),Manual of physical therapy techniques,1989, :239-258.New York: Churchill Livingstone.

6. Shrout, P. E., & Fleiss, J. L. Intraclass correlations: Usesin assessing rater reliability. Psychological Bulletin,1979,86, 420-428.

7. Portney,L.G., & Watkins,M.P. Foundation of clinicalresearch: Applications to practice (2nd ed.), 2000. UpperSaddle River, NJ: Prentice Hall Health.

56 Ganeswara Rao Melam / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Effect of Therapist Applied PNF Stretch Vs Self Applied PNFStretch on Hamstring Flexibility in Young MalesGaneswara Rao Melam1, Syamala Buragadda2, B Praveen Kumar3

1Principal, MM Institute of Physiotherapy and Rehabilitation, 2Assistant professor of Physiotherapy MM University, Ambala, Haryana,3Assistant Professor, Vagdevi College of physiotherapy; Waranga,l A P State

Abstract

Objective

To find out the variation in Hamstring muscle flexibility usingtherapist applied PNF stretch and self applied stretch

Study Design

Pretest post test control group design

Purpose and Significance of the Study

To find out the effectiveness of therapist applied PNFstretch and self stretch on the flexibility of Hamstring muscles.

Participants

30 male students between the age group of 18 to 23 yearshaving hamstring tightness and without any musculoskeletaldisorders formed the population of this study. Subject’s age,height and weight were matched. Informed consent was takenfrom all the subjects. Group I acts as a Control group consistingof 15 subjects who receives Self stretch &Group II acts as aExperimental group consisting of 15 subjects who receivesTherapist PNF stretch.

Key Words

Flexibility, Stretching, Proprioceptive NeuromuscularFacilitation (PNF), Hamstring tightness.

Introduction5In the literature, the terms “flexibility” and “muscle length”

are often used synonymously when referring to the ability ofmuscles to be lengthened to their end range. Flexibility refersto the total range of motion of a joint or group of joints. Thestructural characteristics of the joints and the mechanicalproperties of the connective tissues of the muscle tendonstructures largely affect the extent of movement around a givenjoint. The specificity of movement that a person performs inregular physical activities and stretching methods often definethe development and improvement of the body’s range of motion.

1Stretching techniques are used in clinical practice toincrease flexibility with some support for their use. The flexibilityof the hamstring muscles is important in the prevention of injury,muscular and postural imbalance, and maintenance of full rangeof joint movement, optimal musculoskeletal function andenhanced performance in day to day activities.

43Stretching techniques can be categorized as static,ballistic, slow active and Proprioceptive NeuromuscularFacilitation. Scientific Stretching for Sport (3S) describes amodification of PNF. Numerous investigations establish PNFtechniques as more efficacious treatments than traditional staticstretching exercise for range of motion or flexibility enhancement.

12The Straight leg raising (SLR) test is of great value inassessing normality of the roots of the sciatic nerve and tightness

of the hamstring muscles.7The Value of the SLR test can bedetermined with the goniometer, a gravity type goniometer or atape measure.

The goal of all stretching programs is to optimize jointmobility while maintaining joint stability. Concern should alwaysbe focused on the systematic, safe and effective application ofthe range of motion techniques utilized.

METHOD

Procedure

Previous history of hip or knee or spine injuries, anycontractures or deformities. Neuromuscular, cardiovasculardisorders, any subject missing 4 days without stretching, subjectsinvolving in any other physical fitness program were excluded.Prior to assignment to group each subject who met the inclusioncriteria in the study was measured for flexibility of the righthamstring muscle. Subjects were randomly assigned to twogroups following the initial measurement of hamstring flexibility.

Subjects assigned to Group I [N=15, age =20.3 ± 2.32 range18 – 23 years] served as control group and performs PNF self-stretching.

Group II (N=15, age = 19.8 ± 2.94, Range = 18-23) servedas experimental group and undergone therapist applied PNFstretch.

Both the groups performed stretching 5 times a week for 6weeks. Four repetitions per session with relaxation period of 15sec and stretch period of 15 sec.

The subjects wearing unrestricted clothing were asked tolie supine with the right side of the body parallel with the edge ofthe height adjustable plinth. The trunk and pelvis were placed inthe anatomical position determined by visual inspection.

To avoid compensatory movements [4.5 cm] wide strapswere positioned across the anterior superior iliac spine andproximal third of the left thigh ensure that the lumber spine wasin contact with the plinth, the subject was required to posteriorlytilt the pelvis in order to fix a towel placed between T12 and L5

against the plinth. A standardized explanation and demonstrationwas given to each subject.

Intervention

Group I was instructed to perform and active straight legrise applying all three components of motion to the point oftightness in the hamstring muscles. This included inversion anddorsiflexion of the right foot and toes, raising the right leg byturning the heel towards the opposite shoulder and claspingtheir hands around the back of the thigh. Thereafter, the subjectperformed a hold contraction by attempting to push the straightleg down towards the plinth against maximal self inducedresistance through the hands for 15 sec while the right heelpointed to the right lower edge of the plinth followed by a 15 secrelaxation period when the knee was allowed to bend. Thereafter,the leg was straightened and the procedure was repeated fourtimes.

Group II received the PNF technique applied by thephysiotherapist starting from the agonistic pattern of hip flexion,

57

adduction and external rotation (with knee extension) at the pointof tightness in the hamstring muscles. Thereafter, a ‘holdcontraction’ was performed when the subject attempted isotoniccontraction of the antagonistic pattern; hip extension, abductionand internal rotation which was maximally resisted by thephysiotherapist for 15 sec except the rotational component ofeversion and plantar flexion of foot and toes which was allowedto occur voluntary relaxation period of 15 sec was followed by aresisted contraction of the agonistic pattern moving the legthrough the lengthened range to the point where tightness inthe hamstring muscles was felt. This procedure was performedfour times. Each intervention took 2 minutes consisting of fourrepetitions of 15 sec contraction and 15 sec relaxation period.This procedure was done 5 days a week for 6 weeks.

Subject Position for Passive SLRT

With subjects lying on their left sides, the greater trochanterof the right femur, lateral femoral condyle were identified andmarked with black marker to help ensure proper alignment forgoniometric measurements. The goniometer was placed withstationary arm parallel to the edge of the table, the moving armalong the lateral midline of the thigh and the axis over the superiorhalf of the greater trochanter. The investigator slowly raised theextended right leg with the foot relaxed to the point where thesubject felt tightness in the hamstring muscles.

Before measuring right hip flexion range, the investigatorensured that the lumbar spine was in contact with the plinth by

checking that the towel placed under the subject’s lumbar spinecould not be removed.

Pilot Study

Before going for the main study a pilot study was conductedwith 10 subjects the purpose was to overcome the practicaldifficulties in the treatment.

Data Analysis

Data analysis was performed manually Pre test and Posttest values of the Control group and Experimental group werestatistically analyzed by means of t-test.

The Post test values of Experimental and Control groupwere analyzed by Chi square test (÷2 test). The Significancelevel used for this study is P<0.05

Results

A total of 30 subjects between 18 – 23 years were includedin this study with their mean age group of [20.3 ± 2.32] in Controlgroup and mean age group of [19.8 ± 2.94] in Experimentalgroup.

The study consists of two groups (I and II). Group I consistedof 15 subjects (N=15) who performed PNF self stretch. Group IIconsisted of 15 subjects (N=15) who were given therapist appliedPNF stretch.

Table 1: Comparison of range of motion with in Group I

GROUPS Pre test Post test S.E t Level of Significance 0.05

I 60.06+4.98 82.2 1.31 16.90 highly significant

II 60.90+6.55 87.8 1.75 15.37 highly significant

Table 2: Comparison of range of motion between two groups by using chi square

Group Pre test Post test X2

Experimental 60.90 (A) 87.8 (B)

Control 60.06 (C) 82.2 (D) 0.045 ( no significance)

Total 120.96 (A+C) 170 (B+D)

Fig. 1: Comparing difference between post tests values of control and experimental group

Ganeswara Rao Melam / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

58

Discussion

This study is an attempt to find out any significant differencebetween therapist applied PNF stretch and self stretch groups.The results in this study suggest that there is significant differencein the Pre test and Post test scores of therapist applied PNFstretch and self stretch groups

Wallin et al found an increase of 6.2° of hip flexion rangeafter 14 sessions of a contract - relax method. Sady et al foundan increase of 9.4° in hip flexion range after 18 sessions of acontract - relax - antagonistic - contract method. In both studiesmodified PNF-techniques were used. The stretching regimes inthis study were only performed once for 2 minutes yet appearedto result in greater changes than the published studies describedpreviously.

Bandy et al who applied static stretching to hamstringmuscles found that one stretch session with duration of 30 secand with a follow up of 5 days a week for 6 weeks is the bestintervention method. Boone et al suggested an increase of 3 -4° measured by the same evaluator to determine real change.There the results of this study may be considered to be clinicallyimportant as a range increase beyond 3 - 4° was found. However,although the PNF technique applied by the physiotherapistproduced a greater mean change in range than the self stretchincorporating the PNF components the difference was notsignificant

Limitations of Study

The optimal stretch parameters for stretching exercises arenot known. The results of existing research on the effect ofduration, frequency and repetitions of stretching regimes varyconsiderably. The variation in the change in range of hip flexionamongst the subjects indicates that the effectiveness of thestretching regimes varied across individuals, which was alsofound by other investigators. This may have been influenced bythe physical activity level or other characteristics of the sample.

It was not possible to quantify the force applied by thephysiotherapist although the point of cessation of stretch wasgoverned by the subjects, which was shown to have anacceptable level of error. The generalizability of the study resultsis limited and the small sample size means that the results shouldbe interpreted with care.

The subjects taken were only males so the generalisabilitywill be limited to only males. The small sample size reduced thestatistical power increasing the risk of a type II error. Althoughan attempt was made to stabilize the pelvis by placing strapsacross the left thigh and asking the subject to fixate a towel byposteriorly tilting the pelvis, pelvic movements could notcompletely be eliminated. .

The increase in flexibility of the hamstring muscles shouldnot be extrapolated to other muscle groups as fusiform musclesproduce large range than pinnate muscles.

The Universal goniometer used in this study has scope forerror; an electronic goniometer would have prevented this aspectof error.

Conclusion

Both stretching regimes, which incorporated the facilatatorycomponents of PNF-techniques, achieved a significant increasein hip flexion range. As both stretching regimes achieved clinicallysignificant improvement in range so individual or organizationalfactors can be considered when deciding which stretching regimeto use.

The findings of the present study are important tophysiotherapists who commonly use stretching regimes andteach them to patients as part of the self managementprogramme.

This study concluded that though statistically there is nosignificant difference between self stretch and therapist appliedPNF stretch both are effective treatment methods but therapistapplied PNF stretch is clinically more significant over self stretch.

References

1. A comparison of a self stretch incorporating Proprioceptiveneuromuscular facilitation components and a therapist –applied PNF technique on hamstring flexibility. BirigitSchuback, Julie Hooper, Lisa Salisbury Physiotherapy 90(2004) 151 – 157.

2. The optimal length of time to stretch the Hamstring musclegroup in a seated position using a discomfort scale inindividuals 50 – 60 years of age Manzaris, et al.— Physicaltherapy.

3. Muscle spindles and the regulation of movement. John P.Scholz, Mact and Suzann K. Campbell. - Physical therapyVol. 60(11) 1980 1416 – 1424.

4. The effect of duration of stretching of the Hamstring musclegroup for increasing range of motion in people aged 65years or older. Brent feland, William myrer, et al.- Physicaltherapy. Volume 81, Number 5, May 2001 1110 – 1117

5. Reliability and validity of goniometric measurements at theknee. Gogia et al.

Physical therapy Volume 67, Number 2, February 1987,192 – 195.

6. Measurement of selected Hip, Knee and Ankle joint motionsin Newborns. Gilmore Waugh et al. Physical therapy Volume63/ No.10, Oct1983, 1616 – 1621.

7. Application of Passive stretch and its implications for musclefibers. Physical therapyVolume 81, Number 2, Feb 2001, 819 – 827.

8. Effects of Ankle Dorsiflexion on Active and Passive unilateralstraight leg raising. Gajdostik et al. Physical therapy, Volume65/ No. 10, October 1985, 1478 – 1482.

9. Low – load prolonged stretch Vs High load brief stretch intreating Knee contractures. Kathye et al. -Physical therapy,Vol. 64/ No 3, Mar 1984, 330 ,333.

10. Straight leg Raising test change-yus et al, - Physical therapy,Vol. 63/ Num. 9, Sept 1983, 1429 – 1433.

11. Dynamic Soft tissue mobilization increases Hamstringflexibility in healthy male subjects. Deacon et al. Br.- J.Sports Med 2005; 39, 594 – 598

12. Effects of Viscoelastic properties of tendon structures onstretch shortening cycle exercise in vivo. Ku Bo et al. -Journal of sports sciences, Aug 2005; 23(8); 851 – 860.

13. Type of acute hamstring strain affects flexibility, Strengthand time to return to pre injury level. Askling et al. Br. - J.Sports Med 2006, 40; 40 – 44.

14. Effects of static stretching of quadriceps and Hamstringmuscles on Knee joint position sense. Lund et al. Br. J.Sports Med 2005, 39; 43 – 46. .

15. The use of recovery methods post – exercise. Thomas etal. Journal of Sports Sciences, June 2005; 23(6); 619 –627..

16. Effects of Sub maximal contraction intensity in contract relaxproprioceptive neuromuscular facilitation stretching. Felandand Marin. Ritish- medical journals, 38/4/e18.

17. PNF as a training system. Mel C Siff Ph.D. -Sports ScienceJournals

18. Acute effects of static and proprioceptive neuromuscularfacilitation stretching on Muscle strength and power output.Marek et al. - Journal of athletic training, 2005; 40(2), 94 –103.

19. Proprioceptive neuromuscular facilitation training inducedalterations in muscle fiber type and cross sectional area.Kofotolis et al, April 2004.

20. Hamstring muscle strain - J. Orthop sports Phys.Ther 2005,Jun 35(6); 377 – 87.


59

21. The effects of Hamstring Stretching on range of motion: asystematic literature review. Russell et al. PMID: 16001909.

22. The effect of time and frequency of static stretching onflexibility of the hamstring muscles. Bandy, W. D. Irion, J.M and Briggler, M (1997). Physical therapy, 77, 1090 – 6.Am.- J. Sp. Med.

23. Impact of prior exercise on hamstring flexibility a comparisonof proprioceptive neuromuscular facilitation and staticstretching. Funk et al,- Austin, Texas TX78712, and USA.

24. Effect of stretching duration on active and passive range ofmotion in the lower extremity Robert et al.- University ofSunderland, United Kingdom.

25. The role of mechanical and neural restraints to joint rangeof motion during stretch.- McHugh et al. National instituteof sports medicine and athletic trauma, New York, NY10021, USA.

26. The effect of static stretch and dynamic range of motiontraining on the flexibility of the Hamstring muscles. Bandyet al. - Sports Med, 1997; Nov; 24(5): 289 – 99.

27. Effects of contract relax stretching training on muscleperformance in athletes. Handel etal.University of Tubingen,Germany.-Phys.Ther.1998 Mar; 78(3)321

28. The effect of strength and flexibility training on skeletalmuscle electromyography activity, stiffness and viscoelasticstress relaxation response.Klinge et al. -J. Sports Med 1997Jul; 18(5); 340 – 6.

29. Influences of strength, Stretching and Circulatory exerciseson flexibility parameters of the Human Hamstrings.Weimannk et al. - J. Sports Med 1997 Jul; 18(5); 340.

30. Determinants of musculo skeletal flexibility; viscoelasticproperties, Cross Sectional area, EMG and stretchtolerance. Magnusson et al. Med. Sci. - Sports. Exercise,1996, Jun 28(6); 737 – 743.

31. The association between flexibility and Running economyin Sub elite male athletic distance runners. Craib et al. -Phys. Ther. Sep; 74(9): 845 – 850.

32. The effect of therapeutic muscle stretch on neuralprocessing. Dawson et al. Med. Sci-. Sports. Exerc. 1992Dec; 24(12); 1383 – 9.

33. Effect of Pelvic position and stretching method on hamstringmuscle flexibility. Sullivan et al. Med Sci -Sports Ex, 1992Jan; 24(1); 116 – 23.


60 Gopala Krishna Alaparthi / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Normative Values for Maximal Respiratory Pressures in SubjectsAge 20 to 70 Years. A Cross-sectional StudyGopala Krishna Alaparthi1, Vaishali2, V Prem3, Jaya Shanker Tedla4, Kalyana Chakravarthy5, Ravi Shankar Y6

1Asst. professor, 2,3,4,5,6Associate professor, Department of Physiotherapy, Kasturba Medical College, Bejai, Mangalore-575004

Abstract

Purpose

Respiratory muscle strength is measured as a maximalinspiratory pressure (PI max) and maximal expiratory pressure(PE max). The purpose of this investigation is to obtain normalmaximal inspiratory and expiratory pressure with respect to age,sex, height, weight and BMI in Indian population.

Subjects

In this cross sectional study 250 subjects with age from 20to 70 years were recruited with convenient sampling. They aredivided in to five groups i.e. 20-30, 30-40, 40-50, 50-60 and 60-70. Each group had 50 subjects (males-25 and females-25).

Methods

For measurement of PE max the subject will inhale to neartotal lung capacity (TLC) and then exhale as hard as possibleand for PI max the subjects exhales to near residual volume(RV) and then give a maximal inhalation effort. Threemeasurements were taken for each subjects and the best onewas included for analysis.

Results

The mean value for PI max in male is (75 ± 20 cm H2O)and for PE max is (93± 33 cm H2O) and PI max in female is (48± 16 cm H2O) and for PE max is (60 ± 20 cm H2O).

Conclusion

Data obtained from this study will be useful as simple,reproducible, rapid assessment and interpretation of respiratorymuscle function as well as treatment planning.

Key Words

Maximal inspiratory pressure (PI max), Maximal expiratorypressure(PE max), Respiratory pressure, Muscle strength.Normative data.

Maximal inspiratory and expiratory pressures produced atthe mouth during static efforts are regarded as a reflection ofrespiratory muscle strength. Clinically, respiratory musclestrength is measured as PI max and PE max. The relationshipof these maximal pressures to age, sex, and general muscular

Address for correspondence:Gopala Krishna AlaparthiAsst. professorDepartment of PhysiotherapyKasturba medical college (A constituent institute of ManipalUniversity)Bejai, Mangalore-575004E mail; [email protected]: +91-9916819977

development has been described. Normal values have beenreported for the relationship of maximal respiratory pressuresto age and gender and these are most frequently derived fromthe regression equations of Black and Hyatt.1

The functions of the respiratory muscles are difficult to studydirectly since the muscles have complex origins and insertions.Furthermore, their product, which is the pressure generatedwithin the thoracic cavity, depends on the co-ordinated action ofmany muscles, the individual functions of which may be difficultto distinguish in life. The respiratory muscle pump is vital for themovement of air to the level of gas exchange in the respiratorysystem. The respiratory muscles include diaphragm as the majormuscle of inspiration along with Intercostals and scalenei. It ispossible to assess both the strength and endurance of therespiratory muscles separately. 2

Impairment of the respiratory pump compromisesventilation, gas exchange and tissue respiration. In conditionwhere the load on the respiratory muscles is increased or thecapacity of the respiratory muscles is decreased, muscleweakness can occur.3

Respiratory muscle weakness increase the relative loadfor breathing this can lead to clinical consequences such asdyspnea, impaired exercise performance, ineffective coughing,respiratory insufficiency, weaning failure, and death.3

In this modern world there is a greater increase in pulmonarydisease, there is raising interest in the assessment and treatmentof respiratory dysfunction. Dysfunction of the respiratory musclesis observed in several conditions, such as COPD, Asthma, Cysticfibrosis, Neuro muscular disease including Spinal cord injury,Congestive heart failure and in Critical illness.3

The available studies that reports reference values of PImax and PE max, however, shows wide variability, not onlybetween individuals but also between studies, because of thesmall numbers and subjects selection in these studies. Thenormal values for maximal inspiratory and expiratory pressuresare based on western population. These values are not veryreliable for our clinical assessment, therefore it is essential thatnormal values for the same be predicted through our study.

Respiratory muscle assessment is required to individuallytailor and design pulmonary rehabilitation programme to optimizephysical and social performance.4 Maximal Inspiratory pressureand expiratory pressures varies with demographic variation suchas age, sex. Non-availability of normative data on maximalInspiratory and expiratory pressures in Indian population hadenthused us to conduct this study. Purpose of this study was toobtain normal maximal Inspiratory and expiratory pressures withrespect to age, sex, height, and weight in Indian population.

In this cross sectional study 250 subjects with age from 20to 70 years were recruited with convenient sampling. They aredivided in to five groups i.e. 20-30, 30-40, 40-50, 50-60 and 60-70. Each group had 50 subjects (males-25 and females-25).

Inclusion criteria

1. Age : 20 – 70 years2. Gender: males and females3. At the time of study subjects should be medically fit

61

Exclusion Criteria

1. Known diagnosis of Pulmonary diseases2. Known history of Cardiovascular diseases3. Subject with history of Neuro Musculoskeletal disorders4. Uncontrolled Hypertension5. Uncontrolled Diabetes mellitus6. Psychiatric disorders7. History of Thoracic surgery within 5 years8. History of Abdominal surgery with in 2 years9. Those who are receiving long term medication (steroids)

that could interfere with exercise performance

Instrument

1. Morgan P max monitor [P.K Morgan ltd. ME8 7ED].2. Height and weight scale

Procedure

Advertisement for volunteers in a local newspaper wasgiven for free screening of respiratory muscle function at K.M.Chospital under the guidance of physician. Patients were selectedon the basis of inclusion and exclusion criteria and written informconsent was taken from the subjects prior to test. The subjects

Gopala Krishna Alaparthi / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

also underwent standard chest physiotherapy assessment.Age, height, weight was obtained and BMI was calculated.

For measuring maximum inspiratory and expiratory pressuresthe subjects were made to sit upright in a chair with back support.A nose clip worn with normal flanged mouthpiece behind thelips and gripped by the teeth and was ensured that there is noleak around the mouth piece. For measurement of PE max thesubjects will inhale to near total lung capacity [TLC] and thenexhale as hard as possible. For measurement of PI max thesubject exhales to near residual volume [RV] and then given amaximal inhalation effort. Three measurements were taken foreach subject and best one was included for the analysis. Oneminute of rest was ensured between efforts.12

Data analysis

The values for the maximal respiratory pressures wereobtained by descriptive statistics. SPSS V.11.0 was used foranalysis.

Results

Mean and standard deviation of PI max and PE max formale and female subjects with height, weight and BMI are shownin Table 1 & Table 2.

Table 1: Mean and standard deviation of PI max and PE max for males

PI max PE max Height Weight BMIALL AGE Mean 75.35 93.39 165.70 64.62 23.54

SD 20.89 33.08 7.56 9.73 3.2120-30 Mean 76.03 102.14 167.82 63.28 22.44

SD 18.05 27.12 7.19 10.54 3.2830-40 Mean 78.57 103.64 169.03 64.00 22.42

SD 17.40 24.17 8.17 10.84 3.4940-50 Mean 78.75 109.25 164.28 66.75 24.65

SD 19.84 37.44 7.89 11.64 3.4550-60 Mean 78.36 83.28 164.04 64.64 24.02

SD 26.05 25.22 7.27 7.83 2.5360-70 Mean 65.35 67.57 163.14 64.42 24.22

SD 20.91 31.48 5.75 7.16 2.61

Table 2: Mean and standard deviation of PI max and PE max for females

PI max PE max Height Weight BMIALL AGE Mean 48.80 60.65 155.99 56.41 23.17

SD 16.91 20.28 5.81 9.90 3.8920-30 Mean 46.89 65.51 156.31 51.96 21.18

SD 16.45 23.04 6.72 9.06 2.8930-40 Mean 46.84 59.00 156.08 55.80 22.91

SD 16.28 16.07 4.67 8.72 3.4740-50 Mean 49.32 70.08 153.60 57.16 24.24

SD 14.63 19.90 6.98 9.60 3.9750-60 Mean 51.20 58.12 157.04 58.16 23.59

SD 16.73 22.92 5.54 10.13 4.0460-70 Mean 50.08 49.80 156.88 59.72 24.27

SD 20.82 11.86 4.25 10.82 4.41

Mean values of PI max and PE max for males and females was specified in figure one. Mean height, weight, BMI and age for malesand females were shown in figure two.

Discussion

Maximal respiratory pressures reported in several studies,showed a wide range of variation. We studied the age groupbetween 20 to 70 years. PE and PI max was used to assessrespiratory muscle function in adults. The reported mean valuefor PI max in male is (75 ± 20 cm H2O) and for PE max is (93±33 cm H2O) and PI max in female is (48 ± 16 cm H2O) and forPE max is (60 ± 20 cm H2O).

Compared to previous studies5-11 our study has shown lowermean values for adults. The probable reasons could be

geographical variations, poor motivation in our subjects, anddeliberate leak in the mouthpiece of the apparatus.

Several factors contribute to the wide range of valuesdescribed for adults in previous studies. The first concern was,measurement of PI max and PE max may vary markedly withthe response characteristics of the pressure measuring device.511

Secondly, air leaks at the nose and mouth can produceinaccuracy during forced expiratory manoeuvres. In the majorityof our subjects, detectable air leaks were clearly apparent duringinitial trial studies, but were readily corrected with carefulinstruction.5-11

62

Thirdly, forced respiratory manoeuvres are influenced bymotivation, and finally, the number of trials used to measure PImax and PE max may affect the maximal pressures recorded. Ithas been shown that maximal values recorded may increaseover ten attempts. Thus, Ringqvist5, using ten or more trials,reported higher maximal pressures than Black and Hyatt6 orLeech et al7, who used two and three trials, respectively, todetermine their normal values. Normal values based on a smallnumber of trials may be a more appropriate choice for the clinicallaboratory, where repeated trials may be impractical orimpossible in patients.9

We agree with Black and Hyatt6 that respiratory musclestrength decreases with age. Our study also showed decreasedrespiratory muscle strength in male subjects. Several factorsmay affect respiratory muscle strength in the adults and accountfor inter subject variability in maximal respiratory pressures.Variable changes may occur in skeletal muscle itself, in the elasticrecoil of the lungs and chest wall, and increase in residual volume(RV). These effects differ in individuals and likely contribute tovariability in respiratory muscle strength with ageing.

Increase in RV occur with age and this may lead to analtered. Force-Length relationship of the diaphragm anddiminished static outward recoil of the chest wall, resulting indecreased PI max at RV. This increased RV is not uniform in allpersons and may contribute to differing PI max values in subjectsof the same age. Thus, many factors affects respiratory muscle

strength with increasing age, but the relative importance of eachis unknown.1

Our study also showed decreased PE max in both maleand female subjects, the probable reasons could be, loss oflung recoil and an increase in lung compliance in elderly, whichwould tend to decrease the PE max. Changes also occur in thethoracic wall involving calcification and stiffening of thearticulations of the rib cage together with changes in the spinalcurvature, making the chest wall less compliant. These factorsmay contribute to large interindividual variations in this study.

The measurement of maximal respiratory pressures allowsa simple, reproducible, and rapid assessment of respiratorymuscle function which is extremely useful in following theprogression of respiratory weakness in patients.

Future Research

1. Future studies with large sample size are required.2. Multicentric study is required for predicting regressive

equations for Indian population.

Conclusion

The mean value for PI max in male is (75 ± 20 cm H2O)and for PE max is (93± 33 cm H2O) and PI max in female is (48± 16 cm H2O) and for PE max is (60 ± 20 cm H2O).

Gopala Krishna Alaparthi / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Fig. 1: Mean values of PI max and PE max for males and females

Fig. 2: Mean height, weight, BMI and age for males and females

63Gopala Krishna Alaparthi / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

References

1. Mcelvaney G, Blackie.S, Morrison NJ. Maximal staticrespiratory pressures in the normal elderly. Am Rev RespirDis 1989; 139: 277-81.

2. Pryor AJ, Prasad Ammani S. Physiotherapy for respiratoryand cardiac Problems: Adults and Pediatrics. 3rd edition.Elsevier; 2004, 73-74.

3. Frownfelter D, Elizabeth D. Cardiovascular and pulmonaryphysical therapy. 4th edition. Mosby Inc; 2006, p 453-64.

4. American thoracic society, ATS statement pulmonaryrehabilitation. Thorax 1999; 159: 1666-82.

5. Evan J A, White W A. The assessment of maximalrespiratory mouth pressures in adults. Resp care 2009; 54:1348-59.

6. Black LF, Hyatt RE. Maximal respiratory pressures; normalvalues and relationships to age and sex. Am Rev Respir

Dis1969; 99: 696-702.7. Leech A. Judit G.H, Stevens D. Respiratory pressures and

function in young adults. Am Rev Respir Dis 1983; 128:17-23.

8. Wilson SH, Cooke NT, Edwards RHT, Spiro SG. Predictednormal values for maximal respiratory pressures inCaucasian adults and children. Thorax 1984; 39: 535-38.

9. Smyth J. Robert, Chapman R Kenneth, and Rebuck S.Anthony. Maximal Inspiratory and Expiratory Pressures inAdolescents. Chest 1984; 86: 568-72.

10. Vincken W, Ghezzo H, Cosio MG. Maximal static respiratorypressures in adults: normal values and their relationship todeterminants of respiratory function. Bull Eur PhysiopatholRespir 1987; 5: 435-39.

11. Mishri, Sahoo RC. Maximal mouth pressure estimation asa parameter of respiratory muscle function in healthymedical students. Lung India 2000; 18: 42- 46.

64 Talhatu K Hamzat / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Management of Patients With Concurrent Hypertension andOsteoarthritis of the Knee: Comparative Effect of Using NonSteroidal Anti Inflammatory Drugs and Physical TherapyTalhatu K Hamzat1, Adeolu O Ajala2, Fatai A Fehintola3

1,2Physiotherapy, Department of Physiotherapy, 3Department of Pharmacology and Therapeutics, College of Medicine, University ofIbadan, Nigeria

Abstract

Objective

Non steroidal anti-inflammatory drugs (NSAIDs) arecommonly used in managing osteoarthritis (OA). A patient withOA may have a coexisting hypertension for whichantihypertensive drugs are prescribed. However evidenceindicates that NSAIDs diminish efficacy of antihypertensivedrugs.

Aim

The aim was to determine the respective and combinedeffects of NSAIDs and physical therapy in management of painand reduced functional limitation among patients with concurrenthypertension and knee osteoarthritis (CHKO).

Design

This is a quasi-experimental study technique

Location

Physiotherapy and Medical Outpatient units of a tertiaryfacility.

Methods

Twenty-nine individuals (mean age = 65.71±9.96 years)with CHKO were purposively sampled and assigned to one ofthree treatment groups viz. Physiotherapy and NSAIDS (GroupA); Physiotherapy Only (Group B); and NSAIDs only (Group C).All were on antihypertensive drugs during the study period.Resting systolic and diastolic blood pressure, pain rating andfunctional limitation were assessed using sphygmomanometer,verbal rating scale and the Osteoarthritis Index of Lequesnerespectively.

Results

There was no significant difference in the pain and functionalperformance across the three groups (p>0.05). There wassignificant reduction in pain and increase in functional ability ofthe patients within each of the groups (p<0.05), with greatestwithin-group difference observed in Group C. The NSAID didnot cause a significant difference in blood pressure of all thepatients.

Address for correspondence:DR. T.K.HamzatDepartment of Physiotherapy, College of Medicine (UCH)University of Ibadan, PMB 5017 GPO Dugbe Ibadan 2000001Ibadan, Nigeria. Tel: +234-8052457016/28708056Email: [email protected]/[email protected]

Conclusion

The outcome showed that either Physiotherapy or NSAIDcould bring about the relief of pain and functional improvementin patients with CHKO.

Clinical Rehabilitation Impact

Use of physiotherapy should be considered in managingsymptoms of OA in patients with CHKO especially where drug-drug interaction is envisaged.

Key Words

Osteoarthritis; Hypertension; Physiotherapy; Anti-inflammatory.

Introduction

Osteoarthritis, the most common form of arthritis worldwide,1

causes pain, disability, economic loss and places burden on theindividuals as well as society2. Osteoarthritis can be treated usingpharmacological and or non-pharmacological approaches.3,4,5

Pharmacologic interventions include the use of simple analgesic,non-selective and cox-2 selective non-steroidal anti-inflammatorydrugs, opioids, corticosteroids and chondroprotective agents.4

The NSAIDs work by inhibiting the enzyme cyclo-oxygenase (COX) responsible for prostaglandin synthesis.Cyclo-oxygenase (COX) exists in two isoforms, COX-1 and COX-2. Conventional or non-selective NSAIDs inhibit both COX-1and COX-2, while COX-2 selective inhibitors (Coxibs) inhibitCOX-2 only.6 In order to avoid these deleterious effects, COX-2 selective inhibitors have been developed.7 However, bothnon-selective NSAIDS and Coxibs have similar effects on renalfunction and blood pressure.8

Hypertension may co-exist with OA thereby necessitatingconcurrent prescription of anti-hypertensive drugs and NSAIDs.9

Hypertension can be aggravated or the effects of anti-hypertensive drugs countered in patients receiving treatmentfor both. In a study of drug utilization pattern among hypertensivepatients in a tertiary care setting in South-Western Nigeria, OAwas found to be the second highest co-existing disease withhypertension, after diabetes. The NSAIDs were reported as beingconcurrently taken with anti-hypertensive drugs in this group ofpatients.10 The simultaneous use of these two drug classes,along with the multitude of medical problems in the elderlypopulation that decrease drug metabolism or require multipledrug therapy, may predispose such patients to the risk ofdeveloping drug-drug or drug-disease interactions. 10,11

Pain relief is a key goal in the management of OA, andNSAIDs are more often than not prescribed to manage the pain.3

Physiotherapy is an important non-pharmacologic approach tomanaging OA and has been reported to be effective in itsmanagement4,5, irrespective of the blood pressure status of thepatients. It may therefore be possible to manage some clinicalfeatures of OA such as pain; joint stiffness and functionallimitation in hypertensive patients with physiotherapy only andthus avoid NSAIDs - antihypertensive drug-drug interaction. Thequestion however is how effective would such treatment

65Talhatu K Hamzat / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

approach be in managing pain and improving functional statusin patients with coexisting hypertension and osteoarthritis? Theaim of this study was to determine the comparative individualand combined efficacy of Physiotherapy and NSAIDs in themanagement of pain and functional limitation among patientswith hypertension and OA of the knee.

Methods

Thirty-three individuals diagnosed as having coexistinghypertension and knee osteoarthritis, and who were receivingor seeking treatment at the Medical Outpatients Unit of a tertiaryhealth facility participated in this quasi-experimental study.

Eligibility Criteria

a A physician diagnosed coexisting hypertension and OAaffecting one or both knees (with patients having had thesymptoms more than three months);

b Evidence of clinical features and radiological signs of OA,that is having definite osteophytes and some narrowing ofthe joint space with OA confirmed using American Collegeof Rheumatology criteria.

c Mild hypertension, with the SBP and DBP not exceeding160mmHg and 95mmHg respectively.Prospective patients were excluded (i) if they had any other

significant disorders such as congestive heart failure, renalinsufficiency, diabetes, asthma, because the presence of suchmay be worsened by the drug-drug interaction13 and (ii) if theyhad intra-articular injection of steroids or hyaluronidase in theimmediate preceding 3 months at the time of recruitment intothe study, (iii) if they could not tolerate NSAIDs nor hadcontraindication to the use of Transcutaneous Electric NerveStimulation-TENS.

Procedure

The Institutional Ethics Committee of the institution wherethis study took place approved of the research protocol beforecommencing the study. Procedures and rationale for the studywas explained to the patients and their informed consent wasobtained. Socio-demographic data and clinical history weredocumented for each participant and their baselinemeasurements taken.

These include evaluation of the following:

Pain

The intensity of pain experienced by the patient wasmeasured using Box Numerical Scale. This self-administerednumerical pain rating scale consisting of eleven boxes numberedfrom 0 to 10. Zero represents ‘no pain’ while 10 represents‘maximum pain’ perceived. 14 The use of the box numerical painrating scale was explained to the patient who was then requestedto rate pain at rest and pain on activity on a box numerical scale.

Functional Capacity

The Osteoarthritis Index of Lequesne (OIL), which is anordinal scale, was used to evaluate the subjects’ functionalcapacity and pain or discomfort. It is a condition-specific, validand reliable outcome measure in patients with knee OA14 thatassesses functions that are of primary concerns to OA patients.It has three domains; the first domain assesses pain ordiscomfort, the second domain assesses maximum distancewalked while the 3rd domain assesses activities of daily living.Scoring is indirectly proportional to health status.

Blood Pressure

A mercury-in-glass sphygmomanometer (Manometre,U.S.A.) with a standard size cuff was used to measure the restingblood pressure of the patients in sitting position.

Treatment Group and Schedule

Due to the fact that participants were recruited as theybecame available, they could not be randomly assigned intoone of the three treatment groups, and hence consecutiveassignment method was used.

GROUP A received NSAID and PhysiotherapyGROUP B received PhysiotherapyGROUP C received NSAID.All participants were on their physician’s prescribed anti-

hypertension drugs throughout the duration of the study.

Interventions

A Anti-hypertensive drugs: The patients were already placedon antihypertensive drugs as at the time of including themin this study. These comprised mainly diuretics, centrallyacting agents and calcium channel blockers.

B Non-Steroidal Anti Inflammatory Drugs therapy wasibuprofen (400mg tablet thrice daily). Ibuprofen, the NSAIDof choice in this study has been well evaluated inmanagement of joint pain.

C Physiotherapy. This encompassed.

i. Transcutaneous Electrical Nerve Stimulation or TENS wasapplied to the osteoarthritic knee for 20 minutes.

ii. Therapeutic exercises comprising the following:

a. Quadriceps Setting: The subject, lying in supine position,performed isometric contraction of the quadriceps muscleof the affected lower extremity by drawing up his patellawhile maintaining his knee in extension. The contractionwas held for a count of 10; the patient relaxed and thenrepeated the exercise 10 times. 15

b. Straight Leg Raising (SLR): The subject in a supine positionisometrically contracted his quadriceps muscles(Quadriceps setting) and lifts the lower extremity to about45 degrees of hip flexion while maintaining knee inextension. The position was held for a count of 10, and theexercise was repeated 10 times. The contra-lateral kneeand hip was flexed about 45 degrees to avoid undue stresson the low back.15

c. The subject in a supine position, performed alternatebending and straightening of the affected leg.

d. Hamstring curls: The subject in prone lying with a smalltowel roll placed under the femur proximal to the patella toavoid compression of the patella between the plinth andthe femur, the subject was instructed to ‘bend’ the kneeand hold for a count of 10. This was repeated 9 times.15

e. Full-Arc Extension: The subject in a high sitting position,with a towel rolled under the knees, performs legstraightening and the position was held for a count of 10,and the exercise was repeated 9 times.

f. Stationary cycling: Subject cycled on a non -loadedstationary bicycle for 10 minutes.

Treatment Duration

Duration of participation for each patient was for 8consecutive weeks and physiotherapy was administered threetimes a week for the 8 weeks.

Follow up assessment took place at the 4th and 8th week of

66

treatment and this was carried out by the same clinician whowas blinded to the outcome of the study.

Data Analysis

Descriptive statistics of mean and standard deviation wereused to summarize the data. A One-way Analysis of varianceand Kruskal-Wallis tests were used for as inferential statistics.Alpha level was set at 0.05.

Results

Out of the 33 individuals who were recruited, only 29subjects comprising 19 (65.5%) females and 10 (34.5%) malescompleted the study. Among the four people who dropped out,2 did so after the baseline, one stopped coming for treatmentand could not be contacted by the research team while the 4th

person relocated from the region of this country where the studytook place. All those who dropped out did so before the end ofthe 3rd week of the study. The results presented in this reportare with respect to those who completed the study.

A one-way ANOVA revealed no significant difference(p>0.05) in the physical characteristics across the 3 groups ofsubjects (Table 1) likewise Kruskal-Wallis analysis revealed nosignificant difference in the baseline across the 3 groups in (pre-treatment) pain rating, functional scores, systolic blood pressure(SBP) and diastolic blood pressure (DBP). A similar trend wasalso observed at the 8th week of treatment (Table 2). The within-group analysis showed no significant difference in the SBP andDBP in each of the three groups. However, there was astatistically significant difference in the pain rating and functional

ability in each of the 3 groups (p<0.05). Duncan post hoc test showed the significant difference

lies in pairs (baseline and 4th week), (4th week and 8th week) forboth pain rating and functional scores in each of the groups A,B and C.

Discussion

Non-steroidal anti-inflammatory drugs (NSAIDs) constitutean important group of drugs prescribed to manage pain andinflammation of the joint with osteoarthritis. The patient with OAmay however have a co-existing hypertension for which theyare placed on anti-hypertensive drugs concurrently with NSAIDs.Drug-drug interaction between the NSAIDs and hypertensionmay pose significant danger to the patient especially in terms ofineffective blood pressure control. This is a cause for greatconcern considering that OA is not generally considered a life-threatening disease unlike hypertension which can lead toserious medical complication and eventual death.

The participants in this study were aged above 60 years,which is within the age trend reported in literature as the onsetof these co-existing diseases. A strong linkage between kneeOA and ageing had been reported.16 The fact that (65.5%) ofthe subjects involved in this study were females, giving a 2:1female-male ratio, could be a reflection of the gender pattern ofosteoarthritis among those seeking treatment at the hospitalwhere this study took place. Goodman2 had observed that theincidence of OA is higher in women than men. The primarycomplaint of participants in this study was pain thus corroboratingthe widely held view that the most important clinical factor of OAthat makes patient seeks treatment in pain.3

Table 1: Comparison of mean physical characteristics of the participants in the three groups (n=29)

Group Age (Years) Height (m) Weight (Kg) Quetelet Index (Kgm2)Mean ± SD Mean ± SD Mean ± SD Mean ± SD

A 65.90 ± 9.18 1.65 ± 0.08 81.20 ± 13.67 30.05 ± 5.75

B 65.2 ± 011.9 1.64 ± 0.06 73.40 ± 6.45 27.56 ± 3.61

C 66.11 ± 9.64 1.63 ± 0.07 78.44 ± 7.86 29.66 ± 3.69

f-value 0.02 0.18 1.59 0.88

p-level 0.98 0.83 0.22 0.42

KeyGroup A: Patients who received Physiotherapy and Non Steroidal Anti-inflammatory DrugGroup B: Patients who received Physiotherapy onlyGroup C: Patients who received Non Steroidal Anti-inflammatory Drug

Participants in this study had significant pain relief (p<0.05)with a 64.78% decrease in pain rating among patients in GroupA who received combined therapy of NSAID and physiotherapy,and a 54.79% pain reduction was recorded for Group B patientswho were placed on physiotherapy only while those in Group Cwho were on NSAIDs only had a 56.07% decrease in their painrating. This shows that physiotherapy and or NSAIDs wouldproduce appreciable reduction in pain associated withosteoarthritis of the knee.

There was also significant improvement in functional scores(p<0.05) in all the three groups with the Group B patients(physiotherapy only) recording the highest percentage reduction,followed by the Group A (combined NSAID and physiotherapy)and Group C (NSAID only) respectively. The significant painrelief observed among the participants may be responsible for

resultant improvement in their functional ability. Similar to thefindings of this study, Walker-Bone et al 4 had submitted thatpain relief and functional improvement can be achieved witheither pharmacological or non-pharmacological means, includingexercise therapy. According to Puett and Griffin,17 exercisetherapy alone has been found to be very effective in themanagement of knee OA, especially when electrotherapy isgiven prior to exercise therapy to facilitate tendon extensibilityand muscle relaxation. The transcutaneous electrical nervestimulation (TENS) used in this study is a type of electrotherapymodality. In a comprehensive review by Osiri et al18 to determinethe efficacy of TENS in management of knee osteoarthritis, itwas found out that TENS significantly improved functional status,pain relief and joint stiffness.

The outcome of this study showed that there was no

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67Talhatu K Hamzat / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Table 2: Comparison of baseline and post treatment parameters across the three groups (n=29).

SBP DBP PR FSMean ± SD Mean ± SD Mean ± SD Mean ± SD

BASELINE

Group A 136.40±6.34 84.60±4.08 7.10±1.52 10.45±1.53

Group B 136.00±4.57 85.00±6.25 7.30±1.05 11.25±1.55

Group C 132.00±5.38 84.66±4.21 7.33±1.00 10.66±1.07

KW 3.52 0.61 0.29 1.74

p-value 0.17 0.73 0.86 0.41

POST TREATMENT

Group A 135.90±7.56 88.90±4.40 2.50±1.08 7.50±0.94

Group B 135.00±3.52 85.40±4.69 3.30±1.15 7.95±1.25

Group C 137.11±6.23 88.55±3.28 3.22±0.97 7.94±1.01

KW 0.43 3.19 2.62 1.01

p-value 0.80 0.15 0.21 0.58

KeyGroup A: Received Physiotherapy and Non Steroidal Anti-inflammatory DrugGroup B: Received Physiotherapy onlyGroup C: Received Non Steroidal Anti-inflammatory DrugPR: Pain RatingFS: Functional Status

Table 3: Comparison of clinical parameters wthin each treatment group at baseline and post treatment (n=29)

SBP (mmHg) DBP (mmHg) PR FS Mean±SD Mean± SD Mean±SD Mean±SD

Group A

Baseline 136.40±6.34 84.60±4.08 7.10±1.52 10.45±1.53

Week 8 135.9±07.46 88.90±4.40 2.50±1.08 7.50±0.97

f 0.05 3.19 19.50 15.46

p value 0.95 0.57 0.001 0.001

Group B

Baseline 136.0±04.57 85.00±6.25 7.30±1.05 10.25±1.55

Week 8 135.30±3.52 85.40±4.69 3.30±1.15 7.95±1.25

f 0.05 3.18 16.83 13.90

p value 0.62 0.95 0.001 0.001

Group C

Baseline 132.00±5.38 84.66±4.21 7.33±1.00 10.66±1.06

Week 8 137.11±6.23 88.55±3.28 3.22±0.97 7.94±1.01

f 0.06 3.11 17.68 14.02

p value 0.36 0.09 0.001 0.001

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significant difference in the pain rating and functional scoresacross the three groups studied. This is in consonance with thereport of the study by Lewis et al.19 in which thirty-six non-hospitalized subjects with chronic pain from OA of the kneeparticipated in a crossover evaluation of TENS and naproxen,which is an NSAID. It is significant to note that while lowestreduction in pain rating was observed in Group B (Physiotherapyonly); lowest reduction in functional scores was observed inGroup C (NSAIDs only).

There was no statistically significant difference in bothsystolic and diastolic blood pressure in all the 3 groups. Thismay be because all the participants were on regular anti-hypertensive drugs. Although exercise therapy which is animportant non-pharmacological agent in management ofhypertension was included in the treatment of two of the threegroups in this study, the exercise protocol administered waslocal to the knee region rather than the generalized, endurancetype of exercise which usually have profound effect on thecardiovascular functions of the subjects. The non-significantdifferences observed in SBP and DBP of both Groups A and C(Physiotherapy and NSAID, and NSAID alone respectively) isin line with the study of Bhaligat20 who assessed blood pressureafter one month treatment of 15 women with arthritis andhypertension with thiazide diuretics and ACE inhibitors (anti-hypertensive) and in random order, but sequentially ibuprofen,sulindac and diclofenac. Mean blood pressure was also reportedto be unchanged before and after all NSAIDs and submittedthat the blood pressure action of the combination may not beprostangladin-dependent.20 Also large meta-analyses havesuggested that NSAIDs treatment elevates blood pressure byan average of 5mmHg in hypertensive persons whose bloodpressure had been controlled by drug therapy.21 The varianceobserved in this study, as well as that reported by Bhaligat20 asagainst the report by Pope et al. 21 may be due to the fact thateffects of NSAID on sodium retention are dose-dependent andlow doses of ibuprofen (the drug group used in the present study)may cause less aggravation of hypertension.22 It is howeverpertinent to indicate that the focus of this study is not toinvestigate the influence of NSAID on hypertension.

Side effects of long term administration of NSAIDs includenephrotoxicity23 and diverse upper gastrointestinal adverseeffects, including dyspepsia, erosions, peptic ulcer diseases andcomplications such as bleeding perforation.24 Ibuprofen is arelatively safe and cheap NSAID. Hawkey and Langman11 hadsubmitted that the reduction of risk during routine clinical use ofibuprofen is such that comparisons of safety and efficacy ofreduced doses of ibuprofen (£ 1,200mg daily) seem to worthconsidering in management of OA. The dosage of ibuprofen forthis study was 400mg three times daily. The use of TENS/Exercises as an alternative therapy in patients who havecontraindication to the use of NSAID and other pharmacologicalmanagement may thus be worthy of closer review by all healthpractitioners involved with management of osteoarthritis.

Limitations of this study include the small sample size, shortduration of treatment (eight weeks), non-uniformity in the typeof antihypertensive drugs the participating patients were placedon and the use of quasi-experimental research design.

References

1. Hogue JH, Mersfelder TL. Pathophysiology and first-linetreatment of Osteoarthritis. Ann Pharmacother 2002; 23;122-30

2. Goodman SB. Use of Cox - 2 specific inhibitors in operativeand non-operative management of patient with arthritis.Orthopaedics 2000; 23; 765 - 8.

3. Pavelka, K. Treatment of Pain in Osteoarthritis. EuropeanJournal of Pain 2000; 4:23 -30.

4. Walker-Bone K, Javaid K, Arden N, Cooper C. Medicalmanagement of osteoarthritis. BM J 2000; 321: 936 – 40

5. Sarzi-Puttini P, Cimmino MA, Scarpa R, Carpordi R,Parazzini F, Zaninelli A, Atzeni F, Caresi B. Osteoarthritis:An overview of the disease and its treatment strategies.Semin Arthritis Rheum 2005; 35:1 - 10

6. Breyer MD, Hao C, Qi Z. Cyclooxygenase - 2 Selectiveinhibitors and the kidney. Current Opinion in Critical Care2001; 7: 39 - 40.

7. Hawkey CJ. Cox - 2 inhibitors. Lancet. 1999; 353: 307 -14.

8. Psaty BM, Furberg CD. Cox-2 inhibitors - Lessons in drugsafety. N Engl J Med 2005; 352:1133 –35

9. Chawla PS, Kochar MS. Effect of pain and non-steroidalanalgesics and blood pressure. WMJ 1999; 98: 22 -9.

10. Yusuff KB, Balogun OB. Pattern of drug utilization amonghypertensives in a Nigerian Teaching Hospital. Pharmaco-epidemiology and Drug Safety 2005; 14: 69-74.

11. Hawkey CJ, Langman MJS. Non-steroidal anti-inflammatory drugs: overall risks and management.Complimentary roles for cox-2 inhibitors and proton pumpinhibitors. Br M J 2003; 52:600-8

12. Pavelka, K. Treatment of Pain in Osteoarthritis. EuropeanJournal of Pain 2000; 4:23 -30.

13. Appel GB. Cox-2 inhibitors and the kidney. Clin ExpRheumatol 2001; 19 : 37-40

14. Yeomans, SG. The Clinical Application of OutcomesAssessment, Stanford, Appleton and Lange. 2000; 56: 164.

15. Kisner C, Colby LA. Therapeutic Exercises: Foundationand Techniques. 3rd edition. New Delhi, Jaypee Brothers.1996; 101 - 102, 259 - 60.

16. Kee CC. Osteoarthritis: Manageable scourge of aging.Nurs Clin North Am. 2000: 35: 199-208.

17. Puett DW, Griffin MR. Published trials of non-medicinaland non-invasive therapies for hip and knee OsteoarthritisAnn Int Med 1994; 121:133-40

18. Osiri M, Welch V, Brosseau L, Shea B, McGowan H,Tugwell P, Wells G.Transcutaneous electrical nervestimulation for knee osteoarthritis. Cochrane Database ofSystematic Reviews 2000; 4: CD 00 2823.

19. Lewis B, Lewis D, Cumming G. The comparative analgesicefficacy of transcutaneous electric nerve stimulation and anon-steroidal anti-inflammatory drug for painfulosteoarthritis. Br J Rheumatol. 1994; 33:455-460.

20. Bhaligat K. Effects of non-steroidal anti-inflammatory drugson hypertension control using angiotensin convertingenzyme inhibitors and thiazide diuretics. East Afr Med J2001; 78:507 – 509

21. Pope J.E, Anderson JJ, Felson DT. A meta-analysis of theeffects of non-steroidal anti-inflammatory drugs on bloodpressure. Arch Int Med 1993; 153: 477-484

22. Brater DC, McCarthy DM, Fries JF. Effects of non-steroidalanti-inflammatory drugs on renal function. Focus on cyclo-oxygenase 2 selective inhibition. Am J Med 1999; 107 :6571

23. Cheng HF, Harris RC. Renal effects of non-steroidal anti-inflammatory drugs and selective cyclooxygenase-2inhibitors. Current Pharmaceutical Design 2005;11:1795-1804

24. Kim JW. NSAID-induced gastroenteropathy. KoreanJournal of Gastroenterology 2008;52:134-141

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Comparing Effectiveness of Antero-Posterior and Postero-Anterior Glides on Shoulder Range of Motion in AdhesiveCapsulitis - A Pilot StudyHarsimran K1, Ranganath G2, Ravi SR3

1BPT Student, 2,3Assistant Professor, Department of Physiotherapy, Manipal University, Karnataka, India

Harsimran K / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Objective

To compare the effectiveness of antero-posterior (AP) andpostero-anterior (PA) glide mobilization on external rotation rangeof motion (ROM) in patients with adhesive capsulitis.

Methodology

Patients referred to the department of physiotherapy withthe diagnosis of primary adhesive capsulitis were included inthe study. Subjects were from both gender groups between 35to 70 years of age, with capsular pattern of shoulder. Total of 15participants were included in the study by convenience samplingand were randomized to 2 treatment groups (antero-posteriori.e. AP and postero-anterior i.e. PA) by block randomization. APgroup consisted of 8 subjects & PA group consisted of 7 subjects.Out of 15 subjects 10 completed the study & 5 were lost to followup. Kaltenborn grade III mobilizations were provided to both thegroups, with direction of mobilizations directed anteriorly in onegroup & posteriorly in the other group.Improvement in shoulderexternal rotation range of motion at 45° of abduction was theprimary outcome measure, with secondary outcome measuresas Visual Analogue Scale (VAS) pain scores.

Results

Descriptive analysis of 15 subjects using median andinterquartile values revealed that there was improvement in theprimary & secondary outcome measures in both the groups (AP& PA). There was no clinically significant difference betweenthe 2 groups.

Observation

Both the glides antero-posterior (AP) and postero-anterior(PA) showed to be effective on external rotation range of motionin patients with adhesive capsulitis.

Key Words

Adhesive capsulitis, mobilization, concex-concave rule.

Introduction

Adhesive capsulitis or “frozen shoulder” is one of thecommon pathologies leading to shoulder pain & dysfunction.1

Its prevalence in general population is reported to be 2%, with

Address for correspondence:Harsimran KaurDepartment of Physiotherapy,Manipal college of Allied Health Sciences,Manipal University, ManipalKarnataka, India.Email: [email protected]

an 11% prevalence in individuals with diabetes.2 Denseadhesions & capsular restrictions in the dependent fold of thecapsule is characteristic of this condition.3 Adhesive capsulitisis more common in women between fourth and sixth decade oftheir life.4

The onset of this condition is usually gradual and idiopathic,but it may also be acute and associated with history of minorinjury to the shoulder.5 Adhesive capsulitis has been dividedinto 2 types.3 Primary adhesive capsulitis, which refers to theidiopathic form of a painful and stiff shoulder & secondaryadhesive capsulitis, indicated as a loss of motion resulting frommany predisposing factors such as trauma, diabetes, stroke,upper extremity fractures or surgeries with immobilization.

Adhesive capsulitis is one of the most common, self limitingdisorders of the musculoskeletal system with a duration varyingfrom one to three years.6 Long term range of motion limitationslasting from 2 to 10 years may be suffered by 20-50% patientswith adhesive capsulitis. According to Cyriax, tightness in a jointcapsule results in a pattern of proportional motion restriction,called ‘capsular pattern’ in which the range of motion of externalrotation is more limited than abduction, which in turn is morelimited than internal rotation.7

In Frozen shoulder, there is global loss of both passive andactive range of motion of the glenohumeral joint with externalrotation usually being the most restricted physiologic movement,following the capsular pattern.8,9 This condition can be managedby physical therapy3, medical therapy5, corticosteroidintraarticular injections5, hydroplasty2, manipulation of the jointunder anaesthesia1 & surgical interventions.10 Physical therapycan include stretching, heating modalities, strengtheningexercises and mobilizations.5 Common joint mobilizationtechniques incorporated for improvement in range of motiondeficits are inferior, postero-anterior (PA ) & antero-posterior(AP) glides. According to Convex-Concave rule, the head of thehumerus glides anteriorly during external rotation.1 However inadhesive capsulitis different areas of capsular adhesions maybeseen, such as superior, anterior, inferior & posterior, causingthe humeral head to glide in a direction opposite to the capsulartightness, called the “Capsular Constraint Mechanism”.11

Arthrokinematics of the joints are considerd according tothe convex-concave rule.12,13 However deviations from this rulehave been reported in the literature.14,15 According to Howell etal with elevation and maximal lateral rotation of the arm, thecenter of the humeral head was positioned 4 mm posterior tothe center of the glenoid cavity, which is in contrast to the Convex-Concave rule.13,14 Similarly Harryman et al reported that withextension & lateral rotation, the humeral head translatedposteriorly, which according to him was due to asymmetricaltightening of the capsule during humeral rotation resulting intranslation of the humeral head in the direction opposite to thetightened capsule called “Capsular Constraint Mechanism”.13,15

Mid range mobilization (MRM), end range mobilization(ERM), & mobilization with movement (MWM) techniques havebeen advocated by Maitland,16 Kaltenborn,17 Mulligan.18

respectively. Kaltenborn’s concept of joint mobilization includesthree grades of mobilization.17Grade I are small amplitudedistraction applied with no stress on the capsule, grade II aredistraction/ glide applied to tighten the tissues around the capsule

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& grade III are large amplitude distraction/glide to stretch jointcapsule & surrounding periarticular structures.

Traditionally postero-anterior (PA) glides of the humeralhead have been used to improve external rotation range ofmotion, which is the direction of choice based on the Convex -Concave rule.17 However; Roubal et al & Johnson et al on thecontrary found that antero-posterior (AP) glide is effective inimproving external rotation range of motion in patients withadhesive capsulitis, which is in accordance with “CapsularConstraint Mechanism”.9,19

In order to assess the function of patients with shoulderproblems objectively, measurement of shoulder range of motionwith universal goniometer is advocated. Intratester andIntertester reliability of measuring passive range of motion forlateral rotation of the shoulder complex was found to be similari.e 0.96 and 0.97 respectively.20

Methods

A pre-test post-test study was conducted, involving thepatients referred to Physiotherapy department with the diagnosisof adhesive capsulitis. Subjects included in the study weremales & females between 35 & 70 years of age, in their subacuteor chronic stage with capsular pattern of shoulder i.e. externalrotation range of motion more limited than abduction, which inturn is more limited than internal rotation.Subjects with capsulartightness were differentiated from muscular tightness i.e.subjects with external rotation range restricted that worsenedwith abduction of shoulder were included in the study. Patientswith diabetes, neurological disorders, previous history of traumaor surgery of the affected shoulder were excluded from the study. Total of 15 patients were included in the study by conveniencesampling. Procedure was explained in detail & written informedconsent was obtained from them. Subjects were thenrandomized in 2 treatment groups by block randomization, groupAP (antero-posterior) & PA (postero-anterior). DuringRandomization 3 blocks were used, with each block consistingof 6 units (3 AP & 3 PA). Two blocks out of 3 were utilizedcompletely & from the 3rd block only 3 units were used. Afterallocation, group AP consisted of 8 & group PA consisted of 7subjects.

Investigators

Two investigators (qualified physical therapists) wereinvolved in the study. Primary investigator performed themobilization technique and second investigator was blinded tothe group allocation of the participants and measured range ofmotion before and after every treatment session.

Outcome measures & Instruments

Primary outcome measure selected was external rotationROM at 45°, with secondary measures as Visual Analogue Scale(VAS) pain scores. Universal Goniometer was used formeasurement of shoulder ROMs and 10 cm Visual AnalogueScale was used for recording pain scores.

Procedure

Treatment technique selected was Kaltenborn grade IIImobilizations. Prior to intervention, demographic data i.e. age(in years), height (in cm), weight (in kg), dominant side, affectedside & duration of symptoms (in months) were recorded.Baseline clinical characteristics that were recorded prior to firsttreatment session included VAS pain scores, shoulder abductionROM, internal rotation & external rotation ROM at 45° of shoulderabduction.

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The shoulder range of motion was measured by theuniversal goniometer with the patient in supine on the treatmenttable. The baseline data & subsequent measurements after everytreatment session were recorded by the second investigator ofthe study. Subjects were followed up for 5 consecutive treatmentsessions, with 1 session provided per day. Prior to mobilization,moist heat was applied to the target shoulder for a time period of15 minutes. Patients were positioned appropriately on thetreatment table in supine position for AP glide mobilization (Figure1) & in prone position for PA glide mobilization (Figure 2). Affectedlimb was taken to available abduction range of motion and gradeIII Kaltenborn mobilizations were provided for 30 secondsduration. This technique was repeated for 5 times in 1 treatmentsession. Physiologic movements of the affected extremity wereprovided for 1 minute after every 30 seconds of mobilization

Fig. 1: Antero-posterior mobilization

Fig. 2: Postero-anterior mobilization

procedure. Post mobilization, moist heat was applied again for15 minutes, followed by Codman’s exercises and finger ladderexercises.3 Subjects were then advised to continue the sameexercises at home.

Data Analysis

As being a pilot study, statistical tests of significance werenot used. Data analysis was done using SPSS Version 16.0.Analysis was done by descriptive statistics. Median & Interquartilevalues were observed for all 15 participants. The primaryoutcome of the treatment was based on the change in medianvalues of external rotation range of motion (at 45° & at end rangeof available abduction) from 1st treatment session till the 5th

session and secondary outcomes were based on change in VASpain score from 1st treatment session till the 5th session.

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There was a loss to follow up of 5 participants out of 15,Median values of the lost data were included in the analysis forintention to treat analysis.

Results

Total of 15 subjects gave written informed consent andparticipated in the present study. Out of them 10 participantscompleted all 5 treatment sessions and 5 were lost to follow up.From this lost data 3 were from AP group and 2 from PA group.

Comparison of the median values of the demographic data (age,height, weight, duration of symptoms) of both the groups wasdone (Table 1). Groups were also compared at baseline for VASpain scores and shoulder range of motion (abduction, externalrotation at 45° & end range of available abduction, internalrotation at 45° & end range of available abduction). (Table 2).Median values of VAS and external rotation range of motion (at45° & end of availiable abduction) were compared for changefrom 1st treatmant session to the 5th session. (Figure 3 & Figure4 respectively)

Table 1: Comparison of demographic data by group (Median & interquartile range)

Group Gender Age (in years) Height (in cms) Weight (in kgs) Duration ofSymptoms(in months)

AP M=5 52 164.5 67 3

F=3 (50-57.8) (159-175.2) (55.2-77.8) (3-3.75)

PA M=4 56 161.5 62 1.5

F=3 (49-62) (149-176.7) (57-75) (1-7)

AP = antero-posterior groupPA = postero-anterior groupM = MalesF = Females

Table 2: Comparison of clinical characteristics at baseline by group (Median & interquartile range)

GP VAS ABD IR45 ER45

AP 5.5 90 60 33.5(4.25-7) (90-107.5) (41.25-80) (30-42.5)

PA 5 90 40 20(5-6) (85-120) (30-80) (16-55)

GP = GroupsVAS = Visual Analogue ScaleABD = Shoulder abductionIR45 = Internal rotation ROM at 45° abductionER45 = External rotation ROM at 45° abduction

Fig. 3: Comparison of VAS scores by group (Median &interquartile range)

X-axis: Groups, AP = antero-posterior group, PA = postero-anterior groupY-axis: Difference in VAS scores pre & post treatment

Fig. 4: Comparison of ROMs by group (Median & interquartilerange)

ABD= abduction ROM, IR45= internal rotation at 45° abduction,ER45= external rotation at 45° abduction

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Discussion

The results of present study show that both the mobilizations(i.e. AP & PA) are effective in improving external rotation ROMin patients with adhesive capsulitis. Demographic data of boththe groups was seen to be similar, with the exception of durationof symptoms (DOS), where median value of DOS in AP groupwas 3 months and in PA group was one and half. There were 5males & 3 females in AP group and 4 males & 3 females in PAgroup. Hence both the gender had almost equal representation.Baseline clinical characteristics , showed similarity in VAS painscores, abduction ROM & internal rotation ROM at availableend range of abduction. But variations were observed in external& internal rotation ROM at 45° abduction and external rotationat available end range of abduction.

Five subjects out of fifteen were lost to follow up. Threewere from AP group and two from PA group. Two subjects fromAP group underwent Manipulation under anaesthesia and otherthree subjects could not be followed due to personal constraints.Data of these five subjects was analyzed for intention to treatanalysis. None of the patients included in the study reported ofany kind of trauma or surgery minor or major of the affectedshoulder. All the 15 subjects were right side dominant & nineout of them had their non-dominant side as the affected side.Onset of symptoms was reported to be of gradual in nature inmost of the subjects. At baseline both the groups showedsimilarity with regards to VAS pain scores & reduction in painscores was observed in both the groups over a period of fivetreatment sessions. This reduction in pain was seen to be almostsimilar in both the groups and was considered to be clinicallysignificant.

In case of shoulder ROMs, improvement was observed inall the shoulder ranges in both the groups, with the exception ofinternal rotation ROM at 45° of abduction, where no change inROM was observed over five treatment sessions. This resultcould be attributed to the fact that internal rotation at 45°abduction in most of the subjects was nearly full prior to thetreatment & did not change in subsequent treatment sessions.Improvement observed in ROMs seems to be more in AP groupas compared to PA group, for abduction, external rotation at 45°& internal rotation at end range of abduction, whereas PA groupseems to better for external rotation at end range of abduction.However, the improvements observed are not clinicallysignificant. These changes observed could be due to smallsample size or standard measurement errors.

Results of our study seem to be different from the study byJohnson et al, where improvement in external rotation was foundin AP group, as no clinically significant improvement wasobserved in external rotation ROM at 45° and end range ofavailable abduction in our study. However the two studies arenot comparable as no statistical test of significance wasperformed in our study due to small sample size. Improvementsseen in the primary outcome (i.e. external rotation at 45°abduction) in both the groups could be attributable to either ofthe two mechanisms;Concave-convex rule which might beresponsible for improvement in PA group or capsular constraintmechanism which might be responsible for improvement in APgroup. There were some limitations of the present study likeexternal rotation ROM was not measured at the same availableend range abduction , where the initial value was measuredand Daily pre-treatment VAS & external rotation ROM valueswere not recorded.

Conclusion

Both the glides antero-posterior (AP) and postero-anterior(PA) showed to be effective on external rotation ROM in patients

with adhesive capsulitis. Study with larger sample size andkeeping all the limitations in mind is recommended.

References

1. Roubal PJ, Dobritt D, Placzek JD. Glenohumeral glidingmanipulation following interscalene brachial plexus blockin patients with adhesive capsulitis. J Orthop Sports PhysTher. 1996; 24: 66-77.

2. Andre R, Thierry HM. Adhesive capsulitis. Upper limbmusculoskeletal conditions. Physical Medicine &Rehabilitation articles [Online]. [2009 Oct 15] [Cited 2010April 10]. Available from: http://emedicine.medscape.com/article/326828.

3. Carolyn K, Lynn C. Therapeutic exercise: Foundations &Techniques. 4th edition. Columbus: F A Davis Co; 2002.

4. Smith LL, Burnett SP, McNeil JD. Musculoskeletalmanifestations of Diabetes Mellitus. Br J sports Med 2003;37: 30-38.

5. Neviaser RJ, Neviaser TJ. The frozen shoulder- Diagnosisand management. Clin Orthop Relat Res 1987 (223): 59-64.

6. Neviaser JS. Arthrography of the shoulder joint. Study offindings in adhesive capsu-litis of the shoulder. J Bone JointSurg Am 1962 Oct; 44: 1321-59.

7. Donald A N. Kinesiology of the musculoskeletal system. 3rd

edition. Elsevier science health science; 2002.8. Nicholson GG. The effects of passive joint mobilization on

pain and hypomobility associated with adhesive capsulitisof the shoulder. J Orthop sports Phys ther 1985; 6: 238-246.

9. Andrea J. J. The effect of anterior versus posterior glidejoint mobilization on external rotation range of motion inpatients with adhesive capsulitis. J Orthop sports Phys ther2007 March; 37 (3): 88-99.

10. Paul D G, F Buck W. Adhesive capsulitis and dynamicsplinting- a controlled cohort study. BMC Musculoskeletaldisorders 2009; 10: 111.

11. Peter J.R. Shoulder kinematics in subjects with frozenshoulder. Arch Phys Med Rehab 2003 October; 84: 1473-1479.

12. Kaltenborn FM. Manual Mobilization of the Extremity Joints.4th edition Olaf Norlis Bokhandel (Oslo); 1989.

13. Ar-Tyan H, Tom H, Jia H, Chuong V, Larry H, Sally H et al.Changes in abduction and rotation range of motion inresponse to simulated dorsal and ventral translationalmobilization of the glenohumeral joint. Physical Therapy2002 June; 82 (6): 544-556.

14. Howell SM, Galinat BJ, Renzi AJ, Marone PJ. Normal andabnormal mechanics of the glenohumeral joint in thehorizontal plane. J Bone Joint Surg Am 1988; 70: 227–232.

15. Harryman DT II, Sidles JA, Clark JA. Translation of thehumeral head on the glenoid with passive glenohumeralmotion. J Bone Joint Surg Am 1990; 72: 1334–1343.

16. Maitland GD. Treatment of the glenohumeral joint bypassive movement. Physiotherapy 1983; 69: 3–7.

17. Kaltenborn FM. Manual Therapy for the Extremity Joints.2nd edition. Olaf Norlis Bokhandel (Oslo); 1976.

18. Mulligan BR. Mobilisations with movement. J ManualManipulative Ther 1993; 1: 154 –156.

19. Placzek JD, Roubal PJ, Freeman DC, Kulig K, Nasser S,Pagett BT. Long-term effectiveness of translationalmanipulation for adhesive capsuli-tis. Clin Orthop Relat Res1998 Nov; 356: 181-91.

20. Boone Dc. Reliability of goniometric measurements. Phystherapy 1978; 58: 1355.

73

Effect of Head Down Tilt on Hemodynamics in Valve ReplacementSurgery PatientsAjit Thomas1, Jamal Ali Moiz2, Amit Banerjee3

1Post Graduate Research Student (Cardiopulmonary) Jamia Hamdard, New Delhi, 2Assistant Professor, Centre for Physiotherapyand Rehabilitation Sciences Jamia Millia Islamia, New Delhi, 3Medical Superintendent, LNJP Hospital, New Delhi

Ajit Thomas / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Purpose

After cardiac surgery 90% of patients show basal atelectasiseven on first postoperative day. Removal of secretions in thebasal lobes may require the use of head-down positioning i.e.15-45°.But to position the head down or not still continues to bea dilemma for physical therapist treating the patients with cardiacsurgery as it is believed to be hemodynamically unstable forthese patients. So the purpose of study is to examinehemodynamic effect after head down tilt in valve replacementpatients.

Method

30 patients were included in the study on first post operativeday. Baseline reading of variables i.e. heart rate, systolic bloodpressure, diastolic blood pressure, respiratory rate, and ratepressure product were taken in supine position. After 15 degreesof Head down tilt all the readings of variables were again takenat 1, 5 and 10 min

Result

Except heart rate there was statistically significant increasein systolic blood pressure, diastolic blood pressure, respiratoryrate, and rate pressure product post head down tilt.

Conclusion

Fifteen degrees of head down tilt for 10 min significantlyperturbs the cardiovascular system but no detrimental effect ofhead down tilt (HDT) was observed on cardiovascular system.

Key Words

Hemodynamics; valve replacement surgery; head downtilt.

Introduction

Acquired valvular disease is almost rheumatic in origin.Left heart is more commonly affected than right with mitral 80%of cases, aortic 50%, tricuspid 10% of cases and pulmonaryseldom affected.19 Multiple valve disease accounts forapproximately 15% of all operations on cardiac valves; 80% ofthese operations involve the aortic and mitral operations.According to WHO data, in 2002, about 300,000 people died of

Address for correspondence:Jamal Ali MoizAssistant professor,Centre for Physiotherapy and Rehabilitation Sciences,Jamia Millia Islamia, New DelhiEmail : [email protected] No: 01126981208

rheumatic heart disease worldwide of which 103,913 wereIndians, and about 12 million were still suffering from it worldwide.In 1999 in India, a total 6007 valve replacement or repairsurgeries were performed of which 4640 were mitral valvereplacement, 1967 were aortic valve replacement and 642 wererepair or replacement of other valves.1,2

Types and incidence of postoperative pulmonarycomplications related to abdominal and cardiothoracicprocedures are17

Atelectasis up to 90%Pneumonia 5%-19%Pleural Effusion 49%Pulmonary embolism <1% Aspiration <1%Acute respiratory failureAcute respiratory distress syndromeStudies using multiple inert gas elimination techniques and

CT scanning in cardiac surgery patients on the first postoperativeday showed large areas of atelectasis in the posterior portionsof the lungs with densities largest in basal scans and diminishedgradually towards the apex of lungs.18,10 ‘Chest physiotherapy’is given to maintain or improve alveolar ventilation. In caseswhere alveolar ventilation is reduced secondary to retainedsecretions, various techniques are available to the therapist toassist with secretion removal. Removal of secretions in the basallobes may require the use of head-down positioning i.e. 15-45°19,7 in either right or left side lying to improve ventilation of thenon-dependent lower lobes (through the increased passiveinflationary forces exposed to the non-dependent lung regions),and/or through facilitating drainage of secretions. Studies onsevere cardiac illness and neurological4 patient with head downtilt did not show any delirious hemodynamic change.5,4 But toposition the head down or not still continues to be a dilemma forphysical therapist treating the patients with cardiac surgery, asit is believed that it would be hemodynamically unstable for thesepatients. As hemodynamic effects of head down tilt have notbeen well explored in cardiac surgery patients, the present studyis aimed to see the same.

Material and Method

Design

A pre post test design was used.

Subjects

30 patients (16 female and 14 male aged between 18 to 40years), who were scheduled to undergo either MVR (n=22) orDVR (n=8) were recruited.

Exclusion criteria included moderate to severe respiratorydisease, hemodynamically unstable patient’s i.e. Left ventricularejection fraction d”35, a history of smoking, mean BP d” 60 mmHgand e”110mmHg, ventricular tachycardia ventricular fibrillation,emergency surgery, and patients on pacemaker. Writteninformed consent was obtained from all patients.

74 Ajit Thomas / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Table 1: Patient’s Demographic Data

Subject Mean + SDCharacteristics (n=30)

Age(years) 28.03±7.03

Height(cm) 163.5±4.54

Weight(kg) 46.7±6.81

BMI(Kg/m2) 17.40±1.98

Procedure

All patients included in study were studied 6 hours afterextubation before having any oral feed. Patency of all the ECGleads infusion lines and drainage tubes were checked prior tostudy. Patients were given 30 min rest period in supine beforethe intervention to achieve baseline readings. The level of domewas adjusted and zeroed at heart level. Pre-test baseline readingof heart rate, systolic and diastolic blood pressure and respiratoryrate was taken. Then the patient was tilted in head down positionby other physical therapist and the angle of 15o was measuredwith goniometer by the researcher. Immediately the dome wasagain adjusted and re-zeroed at heart level. The reading ofvariables were taken again i.e. heart rate, systolic and diastolicblood pressure and respiratory rate was taken after 1, 5 and 10min. and the patient was returned back to original position andwas monitored for next half hour. Study was discontinued if thepatient exhibited mean arterial blood pressure <60 mm and>110 mmHg, oxy-hemoglobin saturation less than 90%, fluctuationin heart rate by ± 20 beats per min, any premature ventricularcontractions, any new atrial fibrillations.12


All data were collected and analyzed using SPSS windowsversion14.0. The dependent variables for statistical analysiswere HR, SBP, DBP, RR and RPP. To find out the effect of headdown position on the selected variables, a repeated measureANOVA was used. Pair wise post hoc analysis was used tocompare data obtained pre intervention and 1min, 5min, 10minpost intervention. A p valve <0.05 was considered significant.

Results

Effect of Head Down Tilt on Heart Rate

Repeated measure ANOVA could not find any difference(F=0.736, p=0.503) between the readings of heart rate inresponse to head down tilt.

Effect of Head Down Tilt on Systolic BloodPressure

Repeated measure ANOVA showed a statistically significantdifference (F=13.387, p=0.0001) between the baseline test andpost test readings. To find out effect of time on head down tilt apair wise comparison was done.

Significant increase in systolic BP was seen in 1min, 5minand 10 min post head down tilt with maximum increase of 6.41mmHg from baseline.

Effect of Head Down Tilt on Diastolic BloodPressure

Repeated measure ANOVA showed a statistically significantdifference (F=4.909, p=0.003) between the baseline test andpost test readings. To find out effect of time on The post testreading taken after one and five minutes of head down tilt wasfound to be statistically similar to the baseline reading but thereadings taken after ten minutes was found to be significantlydifferent from the baseline reading. Further it was found thatwith 95% confidence interval, the maximum change in diastolicblood pressure was 4.49 mmHg

Effect of Head Down Tilt on Respiratory Rate

Repeated measure ANOVA showed a statistically significantdifference (f=6.583, p=0.002) between the baseline test and posttest readings. To find out effect of time on head down tilt a pairwise comparison was done using Bonferroni test.

When the post test reading taken after 1 min of head downtilt was compared with baseline reading it was found that therewas a statistically significant difference. Further it was foundthat with 95% confidence interval, the maximum change inrespiratory was 2.5 /min. Similarly when the readings taken after5 minutes and 10 minutes were compared with baseline it wasnot found to be significantly different. So after initial incrementof respiratory rate there was decline of respiratory rate nearlytowards baseline value.

Fig. 1: Effect of Head Down Tilt on Systolic Blood Pressure

Fig. 2: Effect of Head Down Tilt On Diastolic Pressure

Effect of Head Down Tilt on Rate PressureProduct

Repeated measure ANOVA showed a statistically significantdifference (F=7.352, p=0.001) between the baseline test andpost test readings. When the reading taken after one and fiveminutes of head down tilt was compared with baseline readingno statistically significant differences was found. But when thereading taken after 10 minutes of head down position wascompared with baseline values, it was found to be significantlydifferent.

75

Discussion

In the present study patients with valve replacement surgeryon first post operative day were included, A ten min tilt time wasadopted as this has been observed to be an average treatmenttime for patients with heart disease.9 In this study more moderatetilt of 15 degrees was chosen as head-down position has beenassociated with gastro-esophageal reflux in many populations(Heijke et al 1991)21. Dysrhythmias were reported by Hammonet al (1992)6 during physiotherapy with head down position inpatients with acute heart failure; which included pulmonaryedema, particularly when percussions were applied.

However, recently it has become clear that thehemodynamic changes associated with head-down tilt may beclinically important for patients with limited cardiac reserve(Naylor 2005)9. Reducing the degree of head-down tilt reducesthe cardiac stress (Naylor 2006).5

The results of the study indicate that except heart rate therewas significant difference in systolic blood pressure, diastolicblood pressure, respiratory rate and rate pressure product.

There was no significant difference in heart rate from supineto head down tilt which is in accordance with London et al.13

who reported a decrease in forearm venous tone in controls,although BP, HR and baroreflex sensitivity did not change intheir subjects. The results are not in accordance with studies ofNaylor et al.7,Weise at al. 20 where head down tilt resulted indecrease in heart rate due to loading of cardiopulmonarybaroreceptors which decreases muscle sympathetic nervedischarge.8,12 The lack of change in heart rate in present studymay be due to blunted baroreflex response and /or that theincrease in central blood volume was not sufficient to stimulatehigh pressure baroreceptors.5This observation suggests that noalteration took place in cardiac sympathovagal balance inresponse to head down tilt .20

The present study demonstrated an increment in systolicand diastolic BP with head down tilt as cardiac output may haveincreased secondarily to an increase in circulation blood volumeby redistribution of blood from peripheral to central areassubsequent to loss of venous pooling in areas below heart, whichresulted in increased blood pressure.7 It is recognized that headdown position relative to upright position performed in healthysubjects ,induce acute increase in central blood volume,ventricular preload, myocardial oxygen consumption ,cardiacoutput and stroke volume. In this context change in postureincreased ventricular filling by increasing right-sided (cardiac)venous return, thereby influencing the relationship between heartrate and ejection duration. According to Naylor et al 7 there islonger ejection time for same heart rate in head down posturethan supine which reflects a greater degree of myocardial musclefibre shortening following an increase in ventricular filling. Greatershortening subsequent to an increase in filling increases strokevolume via the Frank-Starling mechanism and thus increasingblood pressure.

This is not in accordance with the studies of Naylor et al7,Vijayalaxmi et al16, where the blood pressure were constant orreduced below baseline level probably due to stimulation ofcardiopulmonary baroreceptors which inhibit the vasomotorcentre and reduces efferent sympathetic activity.16 Loading ofcardiopulmonary receptors induces a significant reflex forearmvasodilatation, decrease in total peripheral resistanceaccompanied by decrease in plasma nor adrenalin activity, 13

which in turn reduces blood pressure. The differences in tiltparameters (degrees and time duration), different populationand sample size may explain the apparent inconsistencies.

Functional residual capacity and tidal volume variesconsiderably with body position. FRC at relaxation point is foundto be greatest in standing position and become progressivelyless on passing to sitting, recumbent and Trendelenburgpositions. These changes result from progressive elevation ofdiaphragm, presumably because of pressure from abdominalviscera. So frequency of respiratory rate may have increasedwith reduction in tidal volume presumably to maintain minuteventilation for optimization of breathing pattern with compromisebetween work of breathing and gas exchange. But this incrementin respiratory rate was only seen during the first minute of headdown tilt and reduced nearly to the baseline values after 5 and10 minutes. This finding is in accordance with Fadi et al 1998 14

who studied effect of acute head down tilt on animal model andfound that with approximately 10 seconds of initiation of headdown tilt, central venous pressure increases and reaches aplateau in two minutes. The increase in central venous pressureprogressively stimulates phrenic nerve 20 seconds after theonset of acute head down tilt and reaches maximum within 2minutes and thereafter it tends to decline even though centralvenous pressure remains at plateau. So the increase inrespiratory rate may be due to elevated venous return whichstimulates carotid and intra-pulmonary CO2 chemoreceptorthrough increasing CO2 flow (product of CO2 concentration andblood flow) which transitionally stimulates phrenic nerve activityand increase minute ventilation. And when CVP reaches plateaulevel the respiratory rate returns to baseline level.

There was significant difference in Rate Pressure Productfrom supine to head down tilt which is in accordance with Nayloret al 7 which states that increase in myocardial oxygenconsumption may be due to increase in stroke work, due toincrease in pre ejection phase associated with increaseventricular end diastolic volume7 and increase in afterload. Also,the HDT position is associated with some gravitational stresswhich is relatively less than sitting, such that O2 consumption isgreater than horizontal positions to support cardiac output inthis position11.

Fig. 4: Effect of Head Down Tilt On Rate Pressure ProductFig. 3: Effect of Head Down Tilt On Respiratory Rate


76

Conclusion

The cardiovascular and pulmonary changes observedduring head down position of 15 degree for 10 minutes suggeststhat the maneuver significantly perturbs the cardiovascularsystem.

While the positional changes were not associated withadverse outcomes in hemodynamically stable open heart surgerypatients; they may be detrimental in the presence of abnormalcardiac or baroreflex function. Therefore all vitas signs especiallythe hemodynamics measures should be carefully monitoredwhile rendering the positional changes in intensive care unit

References

1. WHO expert consultation Rheumatic fever and Rheumaticheart disease. Geneva 29 Oct-Nov 2001.

2. Census of India 2001 - Series 1: Registrar General andCensus Commissioner, India

3. Ganong W. Review of medical physiology (15th edition):Prentice Hall, 1991.

4. Susan Berney, Linda Denehy and Jeff Pretto. Head-downtilt and manual hyperinflation in airway clearance. Aus. JPhysiotherapy 2004; 50: 9-14.

5. Justin Nayler, Anthony Mc Lean, Chin-moi Chow, RobertHeard, Albert A modified postural drainage positionproduces less cardiovascular stress than a head downposition in patient with severe heart diseases-A quasiexperimental study. Aust Jour Physio 2006; 52:201-209.

6. Walli E. Hammon, Alfred F. Connors, Robert D, McCaffree.Cardiac Arrhythmias during postural drainage and chestpercussion of critically ill patients. Chest 1992;102:1836-41

7. Justin M Naylor, Chin-moi Chow, Anthony S. Mclean. Cardiovascular responses to short term head down positioning inhealthy and young and older adults. PhysiotherapyResearch International 2005; 10(1):32-47.

8. Goldsmith S, Hasking G. J. Dissociation of sympathateticresponses to baroreceptors loading and unloading incompensated congestive heart failure secondary toischemic or nonischemic cardiomyopathy. Am J Physiol1992; 69: 646-49.

9. Naylor JM, Heard R, Chow CM. Physiotherapist attitudesand practices regarding head-down and modified posturaldrainage in the presence of heart disease) PhysiotherTheory Pract 2005; Apr-Jun;21(2):121-35.

10. Charles Weissman. Pulmonary complications after cardiacsurgery. Semin Cardiothoracic Vasc Anesth 2004; 8: 185.

11. Alice Y. M. Jones and Elizabeth. Body position change andits effect on hemodynamic and metabolic status. Heart Lung2004; 33:281-90.

12. AARC clinical practice guideline. Respiratory Care 1991;36:1418-26.

13. Sibbald WJ, Paterson NA, Holliday RL, Baskerville J. Thetrendelenburg position: hemodynamic effects inhypotensive and normotensive patients. Crit Care Med.1979 May; 7(5): 218-24.

14. Fadi Xu, Zhong Zhang, Donald T. Frazier. Transientrespiratory augmentation elicited by acute HDT inanaesthetized cat. J Appl Physiol 1998;85:492-96.

15. Pannier B, M. A. Slama, G. M. London, M. E. Safar and J.L. Cuche. Carotid arterial hemo-dynamics in response toLBNP in normal subjects: methodological aspects. Journalof Applied Physiology, Vol 79, Issue 5 1546-55

16. Vijayalakshmi. P and Madanmohan. Acute effect of 30o,60o and 80o head-down tilt on blood pressure in younghealthy human subjects. Indian J Physiol Pharmacol 2006;50 (1): 28-32.

17. Jo.Ann Brooks-Brunn. Post operative atelectasis andpneumonia. Heart and lung 1995;24:94-115

18. Arne Tenling, Thomas Hachenberg, Hans Tyden.Atelectasis and gas exchange after cardiac surgery.Anesthesiology 1998; 89(2):371-78

19. James I. Fann, Neil B. Ingels, D. Craig Miller. CardiacSurgery in the Adult. (second edition) McGraw-Hill: 2003.

20. Weise. F, London G. M, Guerin A. P et al. Effect of head-down tilt on cardiovascular control in healthy subjects: Aspectral analytic approach. Clinical Science 1995; 88: 87-93.

21. Heijke S.M, G Smith, A. Key. The effect of the trendelburgposition on lower oesophageal sphincter tone. Anaesthesia1991; 46: 185-87.


77

Efficacy of Motor Relearning Programme on Physical Performanceand Weight Bearing on the Lower Limbs in Sitting Position in PostStroke Hemiparetic SubjectsJatinder Pal Kaur1, Senthilkumar CB2, Venkadesan R3

1Lecturer, Department of Physiotherapy, Khalsa College, Amritsar, Punjab, 2Associate Professor, Cherraan’s College of Physiotherapy,Coimbatore, Tamilnadu, India, 3Senior Lecturer, Department of Physiotherapy, Lovely Professional University, Punjab

Jatinder Pal Kaur / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

The purpose of this study was to evaluate the immediateeffect of a 4 week Motor Relearning Programme (MRP) onphysical performance and weight bearing on the lower limbs insitting position in post stroke hemiparetics.

Methodology

Ten subjects with at least 3 months post stroke wereassigned in a single group by convenient sampling. All thesubjects participated in MRP. Amount of lower limbs weightbearing was measured before and after training by weighingmachine and physical performance by using Fugl MeyerAssessment scale.

Results

A mean improvement in physical performance after MRPwas 52.00± 19.629 and the ‘t’ value of 8.377 was observed inthe study with p<0.05. A mean improvement in weight bearingin involved and uninvolved value of AD, ID, CD after MRP was3.400±3.134, 1.700±0.674, 7.800±2.485, 4.700±3.267,4.400±2.547 and 0.000±1.247 and the ‘t’ value of 3.431, 7.965,9.924, 4.548, 5.462, 0.000 was observed in this study withp<0.05 respectively.

Conclusion

This study provides evidence for the efficacy of MRP onphysical performance and weight bearing on the lower limbs insitting position in post stroke hemiparetic subjects.

Key Words

Hemiparesis, physical performance.

Introduction

According to World Health Organization ‘Stroke can bedefined as ‘rapidly developing clinical signs of focal disturbanceof cerebral function of presumed vascular origin and of morethan 24 hours duration’.1

In India the incidence of cerebrovascular disease was foundto be 13/100,000 population/ year in a study conducted at Vellorein 1969-71 and 33/100,000 / year in a study conducted at Rhotak.A World Health Organisation study in 1999 quoted incidence ofmotality due to stroke in India to be 73/100,000 per year.2

Ischemic stroke occurs due to vascular insufficiency suchas cerebrovascular thromboembolism and haemorrhagic stroke

occurs due to intracerebral or subarachnoid haemorrhage.3

Ischemic stroke accounts for 77%, haemorrhagic strokes 22%and unspecified accounted for 2% of all cases. The risk factorsidentified are hypertension alone in 40%, hypertension withdiabetes in 25%, and hypertension with other risk factors (raisedcholesterol, ischemic heart disease) accounted for another 20%.Diabetes and ischemic heart disease alone were present in 5%cases.4

During reaching activities beyond the upper limbs length ina sitting position, when weight transfer to the feet is at its greatest,the lower limbs help to break forward motion of the body andcontrol balance.5 As a result, the patient must devoteconsiderably more effort to remaining upright, with decreasedability to focus on purposeful tasks.6 The compensatoryinvolvement of the trunk is greater for patients with more severemotor deficits and may be related to impairments of grasping.7

Patients with stroke demonstrate increased postural swayin standing. Delay in the onset of motor activity, abnormal timingand sequencing of muscle activity, and abnormal co-contractionresults in disorganization of the postural synergies.8

It has been reported that more than 70% of stroke patientsadmitted to rehabilitation are unable to reach sideways to thefloor while sitting.9 In addition to paresis, stroke disrupts selectivevoluntary control and can leave the patient with the primitivepatterns of muscle action and spasticity.10

Likewise, purposeful movements requiring precise controlof distal segments (e.g., grasping) are slow, inaccurate and notwell coordinated. 11

While rehabilitation aims to reduce disability by optimizingthe performance of everyday task, on discharge, manyindividuals are significantly disabled and handicapped.12

The persistent disability and handicap experienced by manyindividuals after stroke arises not only from the impairmentsresulting from stroke, but also from the deleterious neural,muscle, psychological and cardiovascular adaptations thataccompany disuse and use of maladaptive behaviors.13

Exercise interventions are the one way to provide on goingprograms to maintain and improve performance after dischargefrom rehabilitation. Such intervention is advantageous becauseit not only provide the opportunity for exercise but also cost-effective .14

The most common are the neurophysiological approach,which emphasizes facilitation and normalization of motorfunction, 15 the orthopedic approach, which is based on themobilization and strengthening of the affected and the unaffectedlimbs to increase compensatory functions, 16 and the motorrelearning approach, which uses active practice of context-specific motor tasks and feedback to regain the lost motorfunctions. 17

Carr and shepherd proposed that training in motor controlrequires anticipatory actions and on going practice. To furtherenhance relearning, the motor task involved are practiced withina context that can be task or environmental specific.18

Need for the Study

The purpose of physiotherapy is to help the patients bearequal weight on both sides in sitting position thereby improvingoverall physical performance using MRP.

Address for correspondence:Jatinder Pal KaurMPT (Neurology), Department of Physiotherapy,Khalsa College, Amritsar, Punjab, IndiaMobile No: +91(0)9878096176E-mail: [email protected]

78 Jatinder Pal Kaur / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Obective of the Study

To investigate the efficacy of MRP on physical performanceand weight-bearing on the lower limbs in sitting position in post-stroke hemiparetic subjects.

Hypothesis

Alternate Hypothesis (H1)

There is significant effect of MRP on physical performanceand weight-bearing on the lower limbs in a sitting position inpost-stroke hemiparetic subjects.

Null Hypothesis (H0)

There is no significant effect of MRP on physicalperformance and weight-bearing on the lower limbs in a sittingposition in post-stroke hemiparetic subjects.

Significance of Study

In the present study, I evaluated the effects of MRP onphysical performance and weight bearing on the lower limbs insitting position in post stroke hemiparetic subjects. MRP seemsto an important treatment intervention to improve affectedfunction and make stroke patients independent in the self careactivities.

This study may provide an insight for the physiotherapistsinto the relationship of MRP with physical performance andweight bearing on the lower limbs in sitting position for makingthe post stroke hemiparetic patients fit for their self care activities.


Reisman DS et al (2007) evaluated deficits in surface forceproduction during seated reaching in people after stroke. Theresults suggest that the normal magnitude and timing of surfaceproduction during beyond arm’s length are altered in people witheven mild hemiparesis after stroke, particularly during reachingtowards the hemiparetic side.19

Michelle et al (2007) investigate the influence of combinedafferent stimulation and task-specific training following stroke.Patients in the stimulation group exhibited significantly greaterimprovements in the group-lift task than control group.20

Joanne M Wagner et al (2007) investigated sensorimotorimpairments and reaching performance in subjects with poststroke hemiparesis during the first few months of recovery. Upperextremity sensorimotor impairments and reaching performancewere evaluated in The detailed clinical assessment of UEsensorimotor impairments measured at the acute and sub acutephase after stroke did not affect the reaching performance.21

Dora YL Chan et al (2006) studied the efficacy of the motorrelearning approach in promoting physical function and taskperformance for patients after stroke. They concluded thatphysiotherapy treatment using motor relearning approach ispreferable to that using conventional approach in rehabilitationof stroke patients.22

Leonard E Kahn et al (2006) investigate the effect ofrobotically administered active-assistive exercise and comparethose with free reaching voluntary exercise in improving armmovement ability after chronic stroke. The group that performedunassisted reaching exercise improved the smoothness of theirreaching movement’s more than robot-assisted group. 23

Sylivie Messier et al (2005) verified weight bearing on thefeet in a sitting position during bilateral movement of the upper

limbs in post stroke hemiparetic subjects. The result of this studyshows that weight bearing on the paretic foot is reduced duringunilateral and bilateral pointing in the anterior, producedsymmetrical weight bearing on both feet, paretic and non-paretic.5

Thielmaj ET et al (2004) evaluated the effectiveness ofTarget Reach Therapy (TRT) and Progressive Resisted Exercise(PRE) for improving paretic limb reaching by chronic subjects.This study showed that TRT resulted in increased substitutivetrunk use at the target ipsilateral to the moving arm and formidline and contralateral targets after PRE.24

Birgitta Langhammer et al (2003) evaluated whether twodifferent physiotherapy regimes caused any differences inoutcome in rehabilitation after acute stroke. They concluded thatphysiotherapy treatment using MRP is preferable to that usingBobath programme in acute rehabilitation of stroke patients.25

Lucia Spinazila et al (2003) studied impairments of trunkmovements following right or left hemisphere lesions. The resultof this study shows that task related circuit training improvedperformance of locomotor tasks in chronic stroke.26

Dean CM et al (1997) evaluate effect of task-related trainingprogram aimed at performance of seated reaching tasks afterstroke. The results show that experimental subjects were ableto reach faster and further increase load through affected foot,increase activation of affected leg muscles compared with controlgroup.9

Beckerman et al (1996) defined criteria for stability asopposed to change of motor function of the lower limb in strokepatients. Intra-class correlation coefficient for the lower limb scalewas 0.86 and 0.34 for the balance scale.27

Mindy F Levin et al (1996) characterize end point trajectoriesand inter-joint coordination of arm pointing movements todifferent targets on a horizontal planar surface and to correlatedisruption in motor control in the affected arm of hemipareticsubjects. The results that the inter-joint co-ordination ofmovements made into or out of the typical extensor or flexorsynergies were typically disrupted.28

Sandford J et al (1993) found the reliability of Fugl-Meyerassessment o f physical performance in patients following stroke.They found that overall reliability was high (overall intra-classcorrelation coefficient = .96) 29

Wade DT, Wood VA et al (1985) evaluated the recoveryafter stroke. First, it confirms that recovery is fastest in the firstfew weeks after stroke but it suggest that it can continue beyondthe first three months. It also suggests that discharge fromhospital coincides with a slowing or stopping of recovery.30

Materials & Methodology

Study Design

Quasi Experimental Design (One group Pre test-Post testDesign).

Study Setting

Four subjects were selected from “Physiotherapy Out-Patient Department, Lovely Professional University at Jalandhar”and six subjects were selected from “Gurudwara Singh SabhaCharitable Hospital at Jalandhar”

Population and Sampling

The convenient sampling method has been used.Ten subjects ranging from 45-65 years of age were included

in the study.

79Jatinder Pal Kaur / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Criteria For Sample Selection

Inclusion Criteria

Age: 45- 65 years, 12 weeks post stroke, Capable toperform in a sitting position without support(Functional BalanceScale grade 2), Both right and left hemiparesis due to stroke,Spasticity grade 1, 1+ and 2 (Modified Ashworth Scale), A goodunderstanding of simple verbal instructions(Mini Mental StateExamination(MMSE) >24).

Exclusion Criteria

Severe cognitive impairment (Mini Mental StateExamination score less than 24), Visual or auditory deficits,Contractures and deformities of the upper limb and\or lower limb,Recurrent episodes of stroke, sensory impairments.

Tools for Data Collection

Fugl Meyer Assessment of physical performance Thecumulative test score for all the components is 226 withavailability of specific subtests scores.

Weighing Scale is a valid and reliable device for measuringthe weight in the clinical setting. (Suvarna, Bhaseen Health Pvt.Ltd. INDIA)

Procedure

After informed consent, during pretest each subject wasevaluated for physical performance by Fugl-Meyer assessmentof physical performance and weight bearing on the affected andunaffected side was measured by weighing machine and theyhad received MRP as per the protocol. The post test resultshave been taken at the end of 4 weeks of treatment. Subjectsreceived MRP for a period of 5 days per week (40 minutes perday of 20 sessions).

Data Analysis

Paired ‘t’ test was used to analyze the significant differencebetween the mean of the pre test values and mean of the posttest values to determine out of the MRP given after a period ofthree months

From table 1, Graph 1, it is inferred that there was gradualimprovement in the physical performance after the MRP. Onanalyzing the pre test and the post test values by paired ‘t’ testthere is significant mean difference 52.00 with SD of 19.629 antthe t value of 8.377 at P <0.05.

From table 2, it is inferred that there was gradual increasein weight bearing on the lower limb while reaching in anteriordirection. On analyzing pre test and post test values of weightbearing on the involved lower limb there is significant meandifference of 3.400 with standard deviation of 3.134 and t valueof 3.431 at p <0.05. On analyzing pre test and post test valuesof weight bearing on the uninvolved lower limb there is significantmean difference of 1.700 with standard deviation of 0.674 and tvalue of 7.965 at p <0.05.

From table 3, it is inferred that there was gradual increasein weight bearing on the lower limb while reaching in ipsilateraldirection. On analyzing pre test and post test values of weightbearing on the involved lower limb there is significant meandifference of 7.800 with standard deviation of 2.485 and t valueof 9.924 at p <0.05. On analyzing pre test and post test valuesof weight bearing on the uninvolved lower limb there is significantmean difference of 4.700 with standard deviation of 3.267 and tvalue of 4.548 at p <0.05.

From table 4, it is inferred that there was gradual increasein weight bearing on the lower limb while reaching in contralateral

direction. On analyzing pre test and post test values of weightbearing on the involved lower limb there is significant meandifference of 4.400 with standard deviation of 2.547 and t valueof 5.462 at p <0.05. On analyzing pre test and post test valuesof weight bearing on the uninvolved lower limb there is significantmean difference of 0.000 with standard deviation of 1.247 and tvalue of 0.000 at p <0.05.

From the table 5, it is inferred that the calculated t- value8.377 at 0.05 level of significance, which was greater than thetabulated t-value of 2.262. This shows that there was significantdifference between pre versus post test result.

From the table 6, it is inferred that the calculated t- valuefor involved side was 3.431 and for uninvolved side was 7.965at 0.05 level of significance, which was greater than the tabulatedt-value of 2.262. This shows that there was significant differencebetween pre versus post test result.

From the table 7, it is inferred that the calculated t- valuefor involved side was 4.548 and for uninvolved side was 9.924at 0.05 level of significance, which was greater than the tabulatedt-value of 2.262. This shows that there was significant differencebetween pre versus post test.

From the table 8, it is inferred that the calculated t- valuefor involved side was 5.462 and for uninvolved side was 0.00 at0.05 level of significance. This shows that there was significantdifference between pre versus post test result on involved limband insignificant difference between pre versus post test resultson uninvolved limb.

Results and Discussion

Stroke is major cause of disability and handicap in adults.Some stroke patients never regain their ability to balancebecause it is never stimulated in a sufficiently specific manner.They soon learn to hold themselves stiffy, to avoid threats totheir balance by maintaining a wide base, or to use only oneside of the body. This results in ineffective limited function and alikelihood of falls. The major reason for ineffective and limitedfunctional ability following stroke is a failure of the patient toreestablish an effective body orienting and balancemechanisms.31

The study aimed to evaluate the effect of MRP on physicalperformance and weight bearing on the lower limbs in sittingposition in post stroke hemiparetic subjects. Among the tensubjects 4 are female and 6 are male.

The selected outcome measures are Fugl Meyerassessment of physical performance scores and weight bearingvalues at the baseline and one month after MRP. The obtaineddata is analyzed by using paired ‘t’ test.

Fugl Meyer Assessment score was taken as parameter tomeasure physical performance. Results shows that there issignificant difference improvement on the physical performanceas calculated ‘t’ value (8.377) for the physical performancemeasure is greater than the table value at p <0.05 and the weightbearing on the lower limbs in sitting position as the calculated ‘t’value (ADI-9.924, ADU-3.265, IDI-3.431, IDU-7.965, CDI-5.462)for the weight bearing measure is greater than the table valueat p <0.05. Results shows that there is insignificant difference inweight bearing with calculated ‘t’ value (CDU-0.00) is lesser thanthe table value at p <0.05.

A significant improvement in physical performance andweight bearing on the lower limb in sitting position in post strokehemiparetic subjects may be a result of intensive training ofaffected side and making the patient concentrate on using theiraffected side for daily activities. MRP is effective for enhancingfunctional recovery of patients who had stroke.

MRP emphasizes sequential and function-based trainingappeared more effective for enhancing the performance of poststroke patients. Motor learning theory describes the ways inwhich motor patterns can be acquired and modified throughexperimental learning such as through observation and repeated


Table 1: Pre and Post test Mean and SD of FMAPPS scores

Variables Mean SD

Pre test Upper Limb score 35.8000 12.56804

Post test Upper Limb score 55.6000 5.64112

Pre test Lower Limb score 17.7000 5.29255

Post test Lower Limb score 29.7000 3.26769

Pre test Balance score 10.2000 2.78089

Post test Balance score 12.9000 1.44914

Pre test ROM score 34.9000 5.66569

Post test ROM score 42.6000 1.34990

Pre test Sensation score 24.0000 .00000

Post test Sensation score 24.0000 .00000

Pre test Pain score 42.8000 1.39841

Post test Pain score 37.3000 6.58365

Pre test Total score 155.6000 27.89345

Post test Total score 207.6000 9.41866

Pre test Percentage score 68.8450 12.34193

Post test Percentage score 91.8590 4.17312

Table 2: Weight bearing value in Anterior Direction

Variables Mean SD

Pre Involved AD 5.3000 0.94868

Post Involved AD 13.100 2.64365

Pre Uninvolved AD 8.4000 1.64655

Post Uninvolved AD 13.100 2.42441

Table 3: Weight bearing value in Ipsilateral Direction

Variables Mean SD

Pre Involved ID 10.1000 3.87155

Post Involved ID 13.5000 2.54951

Pre Uninvolved ID 12.3000 2.94581

Post Uninvolved ID 14.0000 2.49444

Table 4: Weight bearing value in Contralateral Direction

Variables Mean SD

Pre Involved ID 10.9000 3.98469

Post Involved ID 15.3000 2.49666

Pre Uninvolved ID 15.9000 4.60555

Post Uninvolved ID 15.9000 4.86370

Table 5: FMAPPS within the group

Pre Vs Post t value P value

Upper Limb -8.193 P < 0.05

Lower Limb -9.115 P < 0.05

Balance -5.449 P < 0.05

ROM -4.880 P < 0.05

Sensation 0.00 P > 0.05

Pain -3.093 P < 0.05

Total -8.377 P < 0.05

Percentage -8.384 P < 0.05

Table 6: Weight bearing in anterior direction within the group


Involved -3.431 P < 0.05

Un-Involved -7.965 P < 0.05

Table 7: Weight bearing in ipsilateral direction within the group


Involved -4.548 P < 0.05

Un-Involved -9.924 P < 0.05


traditional approaches to rehabilitation of the paretic side.In MRP, the practice of goal-directed, functional movements

is carried out in a natural environment. Studies with thispopulation have shown that MRP improves locomotion and lowerlimb weight bearing in sitting and standing up. Furthermore, arecent study involving positron emission tomography found thatMRP induces brain plasticity in stroke patients.28

Limitations

Small sample size, Previous treatment taken was notconsidered, Right or left hemiparetic population was consideredtogether, Study was done in short period of time which does notprove the long term effect, Results of the study mainly dependon validity of fugl meyer assessment scale, Study has no controlgroup, Modified Ashworth Scale, No follow up was taken.

Recommendations

Based on the outcome of the statistical analysis, it issuggested that the future studies should be modified toaccommodate the following changes:

Large sample size can be taken, Study can be done withnarrow age criteria Young stroke population can be considered,Comparative studies can be done on right and left hemiparesis,A follow up of study is recommended for a more comprehensiveanalysis of recovery of upper limb.

Summary and Conclusion

Based on the analysis, it can be interpreted that MRPproduces significant improvement. In correlating with literatureand statistical analysis, this study conclude that MRP hasproduced significant improvement on physical performance andweight bearing on the lower limbs in sitting position in post strokehemiparetics.

It is evident that such an intervention is effective and it helpsin reducing disease symptoms and improves the generalfunctional well being among these patients with post strokehemiparesis. Therefore, from the literature available and thestatistical analysis of data, it accepted and stated as,

“There is significant effect of motor relearning programmein improving physical performance and weight bearing on thelower limb in sitting position in stroke patients.”

References

1. J.P.H Wade. Neurology for physiotherapist. Chapter 9,clinical aspects of stroke. 4th edition, 240.

2. Bhalla et al. Predicting mortality in stroke, Neurology India,Vol. 50; 3 sept. 2002, pp 279-281.

3. Gord Gubitz, et al: Acute ischaemic stroke, 2000; 320:692-696, British medical journal.

4. PM Dalal, et al: Stroke epidemics in India: Hypertension-stroke control programme is urgently needed, JAPI vol.55,October 2007.

5. Sylvie Maniel, D. Bourbonnais, Yves Roy. Weight-bearingon the lower limbs in a sitting position during bilateralmovement of the upper limbs in a post-stroke hemipareticsubjects. J Rehabil Med 2005; 37: 242-246.

6. Lucia S, Cubelli R, SD Sala. Impairment of trunk movementfollowing left or right hemisphere lesions:dissociationbetween aparaxic error and postural stability. Stroke 2001;32:1875-83.

7. Levin F. SM. Michaelsen. Use of trunk for reaching targetsplaced within and beyond the reach in adult hemiparesis.Exp Brain Res (2002) 143:171-180.

8. Susan B. O’ Sullivan, PT, EdD, Physical Rehabilitation 5th

ed. 2007, page 705.9. Dean CM, Shepherd RB. Task-related training improves

practice. People with brain injury have deficits in motorprogrammes, motor memory and associated feedback and feed-forward mechanisms, which largely impede their functionalperformance. The motor relearning approach promotes theregaining of normal motor skills through task-oriented practicewith appropriate feedback and the active participation of thepatients.26

Improvement in physical performance and weight bearingon the lower limbs in sitting position noticed in this study may bedue to reason that MRP would have helped to reduce the diseasesymptoms and thereby improving the physical performance andweight bearing on the lower limbs in sitting position in post strokehemiparetic subjects.

Evidence shows that large number of post strokehemiparetic subjects experience balance impairments due toabnormal movement and postural reactions. The abnormalmovement and postural pattern is referred as motor dysfunction.We also know that there are effective interventions for theseabnormal movements and postural reactions. MRP aimed atcorrecting the abnormality of movement thereby improving thephysical performance and weight bearing on the lower limbs insitting position in patients with post stroke hemiparesis.

To execute reaching tasks in sitting position requires acoordinated movement of the trunk and the lower limbs to keepthe body stable and maintain balance. Reaching movementbeyond upper limb length in a sitting position increase posturaldemands since part of the body weight supported by thighs onthe chair is transferred to the base of support provided by feet.5

Trunk flexion in anterior direction and towards the pareticside requires activation of the trunk extensors on the non-pareticside to control trunk flexion. However, trunk flexion towards thenon paretic side requires greater use of hemiparetic muscles ofthe trunk. Muscle weakness on the paretic side of the trunkcreates an ability to generate enough muscle activity to providenecessary braking when moving the trunk in the non pareticdirection. This inability probably created the need to use theparetic foot in hemiparetic subjects to maintain their balance.5

Specific training or repetitive exercises are known toincrease the cortico-spinal excitability and improve function ofthe paretic side.24 Task-specific physiotherapy involving repetitivepractice of the meaningful daily activities is more effective than

Table 8: Weight bearing in Contra-lateral direction within thegroup


Involved -5.462 P < 0.05

Un-Involved 0.00 P > 0.05

Graph 1: Comparison of pre and post test Mean and SD ofFMAPPS score

82

performance of seated reaching tasks after stroke. Arandomized controlled trail. Stroke 1997; 28:722-8.

10. Carolyn P. Weakness and strength training in persons withpost stroke Hemiplegia; rationale. Methods and efficacy.JRRD 2004:293-312.

11. Lang CE et al. Recovery of grasp versus reach in peoplewith hemiparesis post-stroke. Neurorehabilitation Neuralrepair 2006:20:444-454.

12. Hill K, Ellis P, Bernhardt J, Hull S. Balance and mobilityoutcomes for stroke patients: a comprehensive audit. AustJ Physiotherapy 1997; 43:173-80.

13. Tangeman P, Banartis D, Williams A. rehabilitation forchronic stroke patients: changes in functional performance.Arch Phys Med Rehabil 1990; 71:876-80.

14. Carr JH, Shepherd RB. Neurological rehabilitation.Optimizing motor performance. Oxford: ButterworthHeinemann; 1998.

15. Bobath B. Adult Hemiplegia: evaluation and treatment, 2nd

edition .Butterworth Heinemann.1990.16. Partridge CJ. Neurological physiotherapy: a problem solving

approach. Churchill Livingstone, 1996.17. Carr JH, Shepherd RB: A motor relearning programme for

stroke. Butterworth Heinemann physiotherapy, 1987.18. Sabari JS. Motor learning concepts applied to activity-based

intervention for adults with Hemiplegia. Am J Occup Yher1990; 45:523-30.

19. Reisman DS, JP Scholz. Deficits in surface force productionduring seated reaching in people after stroke. Phys Ther.2007; 87; 326-336.

20. Michelle N, Mcdonnell. Influence of combined afferentstimulation and task specific training following stroke: a pilotcontrolled Trial. Neurorehabil Neural Repair 2007; 21; 435.

21. Joanne M Wagner, Catherine. Sensorimotor impairmentsand reaching performance in subjects with poststroke

hemiparesis during the first few months of recovery.PhysTher. 2007; 87:751-765.

22. Leonard E Kahn, Michele. Robot-assisted reachingexercise promotes arm movement recovery in chronichemiparetic stroke: a randomized controlled pilot study.Journal of Neuroengineering and rehabilitation 2006,3:12

23. Thielman GT, Dean CM. Rehabilitation of reaching afterstroke: task related training versus progressive resistiveexercise. Arch Phys Med Rehabil 2004; 85:1613-8.

24. Birgitta Langhammer, Stanghelle JK. Bobath or motorrelearning programme? A follow-up one and four year’s poststroke. Clin Rehabil 2003; 17; 731.

25. Kusoffsky A. reaching-lifting-placing task during standingafter stroke: Coordination among ground forces, anklemuscle activity, and hand movement. Arch Med Phys Rehail2001; 82:650-60.

26. Mindy F. Levin. Interjoint coordination during pointingmovements is disrupted in spastic hemiparesis.Brain(1996), 119,281-293

27. Sandford J, Moreland J, Swanson LR. Reliability of thefuglmeyer assessment for testing motor performance inpatients following stroke. PhysTher1993;73:447-454.

28. Wade DT, Wood VA, Hewer WL. Recovery after stroke-thefirst three months. J. Neurol. Neurosurg. Psychiatry 1985;48:7-13.

29. Carr JH, Shepherd RB. A motor relearning programme forstroke. Oxford: William Heineman Medical Books; 1982.

30. Michaelson SM, Luta A, Roby Brami A,Levin MF. Effect oftrunk restraint on recovery of reaching movements inhemiparetic patients. Arch Med Rehabil 200; 81:95-101.

31. Carr, J.H. and Shepherd. Some factors influencing theoutcome of stroke rehabilitation. Aust. J. Physio ther. 25;4,August,1979.

Jatinder Pal Kaur / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

83

The Effect of Low Power Laser Acupuncture on Experimental PainThreshold in Normal SubjectsJavan Amoli M1, Ebrahimi I2, Marofi N3, Javan Amoli M4

1Emam reza hospital, Mazandaran University of Medical Sciences & Health Services,Amol, Iran, 2,3Rehabilitation faculty, Iran Universityof Medical Sciences & Health Services, Tehran , Iran, 417 Shahrivar Hospital, Mazandaran University of Medical Sciences & HealthServices,Amol,Iran

Javan Amoli M / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

In This research the immediate & latent effect of low powerGa-Al-As laser irradiation applied to acupuncture points onexperimental pain Threshold were studied.

Material & Method

Study design was quasi experimental, seventhy adultwomen Ranging in age from 20-40 years assigned randomly toone of two groups. Laser group (n=33) received L.P.L Ga-Al-Asto appropriate acupuncture points for wrist pain, control group(n=37) received placebo laser, this research was single blind.We measured experimentally induced pain threshold atipsilateral nondominant wrist following electrical stimulus, oncebefore treatment and three times after treatment with shortintervals.

Parameters for laser were, wavelength , 780 nm; powerout put, 5mw and acupuncture points; L.I.4 & L.I.5 each pointwas treated for 60 sec which amounted to 0.3 j/point, radiationtechnique was direct contact. Parameters for electrical stimuluswere, monophase squar wave with a duration of 5 ms; interpulsinterval, 500 ms and intensity , 0-30 mA.

Results

The laser group demonstrated a statistically significant(p=0.001) increase in mean value for pain threshold at 10 minutsafter treatment, but control group did not Also changes of painthreshold in laser group were greater than of control group. Thisincrease remained significant only at 10 minuts after treatmentmeasurments (p=0.001).

Conclusion

Low power Ga-Al-As laser radiation to acupuncture pointscan increase experimentally induced pain Threshold.

Key Words

Pain threshold, laser, experimental pain, acupuncture.

Introduction

Acupuncture is an indispensable part of traditional chinesemedicine and has a history of four thousand years.It continusesto be used extensively in clinical practice.

Acupuncture treatment is especially applicable to thetreatment of musculoskeletal and soft tissue conditions , whereit is particularly effective. Many of these conditions can not besatisfactorily treated by drugs due to the large number of sideeffects and the high cost treatment. Its value in the managementof pain has become widely accepted and it is presently offeredas a powerful and effective therapy.1

The commonest alternative related the techniques in thispoints include the use of electric currents, particularly Tens andlow energy laser. 2,3

Laser acupuncture offers distinct advantages overtraditional needling, because the procedure is non invasive,

painless and free infectious complication , so it is more appealingto the patients, Also it can be useful in shortening the timerequired to resume rutine work the patient. Also combined withother therapeutic modalities. 2, 4 , 15

Laser acupuncture treatment is inexpensive , higly effectiveand has no side effects. 4

Material & Method

This study design was quasi experimental and conductedon 70 women of between 20-40 years old , the persons wereannounced healthy regarding neurologic and orthopedicproblems and pain free ,they psychologically had no reaction toelectric stimuli and All the persons had written consent . due tothe limitation of subject selection, it was non random andvolunteers were selected for the study but they were randomizedinto two groups using elow power laser and placebo inacupuncture points of the wrist pain respectively. This study wassingle blind and was conducted without the subjects awarenessof the possible results. The instruments in this study consistedof:1. Electrical stimulator which produced a monophase square

wave with a duration of 5 ms and intervals of 500 ms andthe frequency 100 HZ. The active electrode was a 2mmdiameter pen electrode that created acute pain in ipsilateralnondominant wrist (figure1).

The inactive electrode was a carbonized silicon electrodeof 6× 8 cm size that being placed on 7th cervical vertebra. Thisexamination include four times, once before and three times(immediately, 5 minuts, 10 minuts) after laser radiation.

First detectable sensation threshold as well as painthreshold were determined. Via the methods – limits technique,the current was increased from zero at a constant rate(approximately 1.5 mA/s) until light tapping (sensation threshold)was perceived. Stimulus was then immediately turned off, andthe procedure was repeated three times. The average of threecurrent levels was taken as the true sensory threshold in thedistal end radius. For pain threshold , the same process wasrepeated, but the intensity was increased in 0.3mA steps untilthe first pain (pain threshold) was perceived.

Fig.1: Location of stimulating electrode-distal end of left radiusin this study

84 Javan Amoli M / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

2. Gallium- Alluminium – Arsenide laser which producedcontinuse radiation with wave length of 780 nm, the out putof 5 mw and 0.3 j/point energy, radiation technique wasdirect contact. Laser radiated on L.I.4 (Hegu) and L.I.5(Yangxi) points that before has determined(figure2&3).16

The time intervals were also checked for control group.

Fig. 2: Location of acupuncture point L.I.4 (hegu) on the largeintestine channel in this study.

Fig. 3: Location of acupuncture point L.I.5 (yangxi) on the largeintestine channel in this study.

Results

The statistical package for the social sciences(SPSS) wasused for the analysis . 75 subjects was volunteered, that 5 caseswere excluded from study .

In the study laser group, one way variance analysis testshowed that pain threshold in 10 minuts after laser radiationwith p=0.001 an increasing trend.

In the control group, no significant change was detected in painthreshold in various time intervals.

Table 2: Mean of pain threshold in control group.

Time (min) Pain threshold

X SD

Before treatment 3.58 1.17

Immediately after 3.54 1.13treatment

5 minutes after 3.49 1.15treatment


Also the independent t.test showed that between meansof pain threshold two groups, there was a significant differencewith p=0.001 in 10 minuts after laser radiation.

Discusion

There was significant changes in pain threshold in 10minutes after radiation, which may be due to the relieving effectof acupuncture points and laser together. The laser not only

Table 1: mean of pain threshold in laser group.

Time (min) Pain threshold

X SD

Before treatment 3.34 1.22

Immediately after 3.46 1.28treatment



85

gives the acupuncture effect, but also has its own anti inflamatoryeffect on the tissues. low power laser has a photochemical (notthermal) effect on the cells, the light energy is absorbed by thecell and converted to chemical energy. Cell function improves,allowing healing to take palce, enzymes such as endorphinsand serotonin are released to give pain relief.11

Laser energy transfering through out meredian and lateralchannels and creating analgesic effect.8 also increases the painthreshold of never ending.9

The therapeutic effect of L.P.L is not fully understood butking etal demonstrated that Helium- neon laser radiation onauricular acupuncture points elevates the pain threshold byraising the level of endorphins in the brain.8Stimulation ofacupuncture points can raise the endorphin level in the brain12,and can lead to an increase in activity of the opiodergic system,including panopoid activity and beta endorphin levels in plasma.12,14

We found comparable results with king et al. 8Although theyused continus Helium- neon laser on auricular points anddetected immediate change in pain threshold, which may beduo to laser type used. GA A1AS lasers may be more effectivefor analgesic effects in the deep and superficial tissu,respectively.5,6,7also treatment parameters, numbers and kindof points that was received laser radiation.

In this study we have focused on the effect GA AL AS laserin healthy individual on experimental pain. Due to the manyvariables involved in pain and lack of visible objective findingsand the effect of many cultural and psychological factors onpain expression , evaluaton of pain in real context is not apractical way. So experimental pain stimuli were used in thisstudy.8

In control group , in all times test no increase was detectedin pain threshold, Even small decrease occurred in this group,the repetition of stimuli can result in increase in perception whichmay be due to hyper sensitization of peripheral pain receptorsor in upper nervous levels.since noticed no changes significantin pain threshold before and after placebo radiation , can bedescribe that in control group there was’nt instruction effect. 10

Conclusion

Low power Ga-Al-As laser radiation to acupuncture pointscan increase experimentally induced pain Threshold.

Acknowledgments

I would like to express my thanks to the following individuals:Dr.Javan Amoli.M. anesthesiologist, Dr.Ebrahimi,I, PhD PT&Dr.Marofi.Nfor their assistance in this study; Iran university ofmedical sciences & health services, research affair for financialsupport and permission of accomplish. This Research was donein the physiotherapy clinic in Yahya Nejad hospital ofBaboluniversity of medical sciences & health services in Babol,Mazandaran, Iran. and finally, I extend special thanks to all ofmy subjects&coworkers of physiotherapy clinic in yahya nejadhospital,Dr.Javadian.Yahya,P.H.Dpt.DrJavanshir. Khodabakhsh,P.H.Dpt,Abdollah zade.Adel,M.Sc.PTt.

Refrences

1. Lu shaojie. Hand Book of Acupuncture in the treatment ofmusculoskeletal conditions. Copyright C 2002 by Donicapublishing Ltd. P,1-3, 150.

2. Wong TW, fung kp. Acupuncture from needle to laser , familypractice 1991; 8(2): 168-70.

3. Snyder-Mackler L, seitz L. Therapeutic uses of light inrehabilitation. 2 nd ed. Philadelphia, pa; Davis co ; 1990,P.200-218.

4. New light on pain the ancient chinese therapy ofacupuncture has gonehitech. (Article from: Herald sun)march, 14, 2007. P:2

5. Schwanitz R. The position of acupuncture and theimportance of its methods in sports medicine. Abstracts,third world congress of scientific Acupuncture, I CMART‘88’ prauge. Cited in pontinen PJ.Chapter 17 “low energyphoton therapy” in schoen AM and wynn SG(eds):Complementary and alternative veterinary medicine,principles and practice. St. louis: Mosby , 1998. PP. 247-74.

6. Shiro T and Galderhead RG. Low level laser therapy: apractical introduction. Wiley: chi chester, England, 1988.

7. Narda G Robinson, Do, DVM, MS. Laser Acupuncture:Healing with light. Copyright march, 14, 2007.

8. King -CE: celelland -JA; knowles-CJ; jackson-JR:effect ofhellium-neon laser auriculo therapy on experimental painthreshold. Physther 1990; 70(1); 24-30.

9. V.A. Buylin, S.V. moskvin: low intensity laser therapy of


86

various Diseases. Moscow. “Technika” Firm, Ltd, 2001.P:13.

10. David ottoson physiology of nervous system. First published1983. P: 460-461.

11. Article from herald sun: what is laser Acupuncture March,14 ,2007. PP:1

12. Pintov S, lahat E, Alstein M, Vogel Z, Barg J. Acupunctureand opioid system: implications in management of migrain, pediatr Neural 1997; 17(2); pp:120-3.

13. Sunshine A , Olson NZ. Non narcotic analgesics. In: wallPD, Melzack R editors, Text Book of pain,second edit.churchill Livingstone.Edinburgh London Melbourne & NewYork.1991.PP: 670-85.


14. Narges sadat Ebneshahidi, Mojtaba Heshmatipour, AlirezaMoghaddami, Payam Eghtesadi- Araghi - Araghi: The effectof laser acupuncture on chronic tension headache arandomised controlled trial. Acupuncture medicine 2005;23(1) : 13-18.

15. Ilbuldu E, cakmak A, Disci R, Aydin R: comparison of laserdry needling and placebo laser treatments in myofascialpain syndrome. Photo med laser surg. 2004, Aug; 22(4):306-11.

16. An outlin of chines acupuncture the academy traditionalchines medicine 1979.p:39.

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Influence of Graded Aerobic Exercise in Post-surgical AdultAcyanotic Congenital Heart Disease - A Prospective RandomizedClinical TrialK Madhavi1, Abhachandra2, Arun G maiya3

1Principal, College of Physiotherapy, 2Head of the Department, Cardiovascular and Thoracic Surgery, SVIMS, Tirupathi, 3AssociateDean, MAHE, Manipal

K Madhavi / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Exercise intolerance and Impaired quality of life is the longexisting problem in Adult congenital heart disease individuals.Regular physical activities improves the physical capacity of anindividual., influence on exercise tolerance and quality of lifeneed to be studied. The aim of the study is to find out theinfluence of graded aerobic exercise on post surgical adultacyanotic congenital heart disases.


111 samples were randomly selected from a tertiary carecentre SVIMS, Tirupathi, AP and allotted into control and studygroups. The outcomes measures in the study were BMI (kg/m2),Ejection fraction (%),Nitric oxide (mmol/L), VO2 peak (ml/kg/min) and Quality of life (score).BMI was recorded usingQuetelet index, Ejection fraction through echo, Nitric oxideanalysis by Griess method , Bicycle ergometer to measure theventilatory oxygen peak uptake (VO2 peak) and self assessedhealth related quality of life questionnaire SF-36 form to assesshealth related quality of life. The above values were recordedbefore surgery and 12 weeks after surgery. Graded aerobicexercises were implemented from the day 1 after surgery to 12weeks to study group. Un graded aerobic exercises wereimplemented from the day 1 after surgery to 12 weeks to controlgroup.

Results and Statistical Analysis

Power of the study is 90%. Paired t-test is used to comparemean values between pre and post tests of each parameterand t test is used to find out the mean percentage change in theparameters. The mean difference of pre and post interventionvalues of all outcomes between study and control group werefound to be significant at p value <0.001. Mean percent changeof various study parameters between control and study groupwere also found to be significant at p value.<0.001.

Conclusion

Implementation of graded aerobic exercises in post surgicaladult acyanotic congenital heart disease individuals hasimproved exercise tolerance and quality of life.

Introduction

The congenital heart disease (CHD) is nothing but a grossstructural abnormality of heart or large vessels present at birth.Congenital disease of the heart and circulation are not fixedanatomic defects but, they are dynamic anomalies that originatein foetal life and change considerably from foetal life to adulthood.Approximately 85% of the babies born with cardiovascularanomalies are expected to reach adulthood.1 The acyanoticcongenital heart diseases are classified into mild, moderate andsevere lesions. The mild and moderate categories includeacyanotic lesions where as the severe ones include all adultcyanotic heart diseases and a few acyanotic lesions. Theincidence of mild and moderate forms of ACHDs is 3/1000 live

births. About 40% of them survive without treatment while 75 to80% can survive with treatment. 2

The incidence of complex lesions is about 2.5-3/1000 livebirths. About 40% survive with treatment. Genetic as well asenvironmental factors cause most of the CHDs.

Many samples with CHD need medical and surgicalinterventions and follow up for life long. Apart from medical andsurgical follow up, the issues that matter most are pertaining totheir physical capacity and quality of life (QOL). Though regularphysical activity can enhance general health, the long termcomplications of these samples have become the cause forconcern. The most important of them are exercise intoleranceand impaired QOL. There are a number of studies done onexercise testing and quality of life. Very few have done on theeffectiveness of physical activity on ACHD and the studies haveproved to be beneficial. However the studies have notconcentrated on structured aerobic exercises and its effect onexercise capacity and QOL.

The pathological reasons behind exercise intoleranceamong the samples of ACHD are mainly due to shunting lesions.Apart from diversion of blood flow, the physiological changesthat occur in CHD are rapid fall in pulmonary vascular resistance,increase workload to left ventricle, decreased oxygenconsumption and erythrocytosis.

The diversion of systemic venous blood from pulmonarycirculation into the systemic arterial circulation is a fundamentalpathologic fault in samples with CHD. Regular exercise maysignificantly increase the degree of venoarterial mixing andinfluence the dynamics of oxygen uptake and ventilation. Theprolonged onset and recovery of ventilatory oxygen (VO2)kinetics results in large oxygen deficits and hypoxemia, evenwith low levels of exercise. The samples with right to left shuntsmay rely to an unusual degree of anaerobic metabolism toperform exercise. Right to left cardiac shunting of CO2 andincrease dead space within the lung are the major factorsaccounting for high ventilatory requirements during exercise.Hence the implementation of aerobic exercise helps to decreasethe anaerobic metabolism, decrease lactic acid buildup andthereby reduce the fatigue levels in ACHD. With exercise, localblood flow is controlled by chemical factors, metabolites,paracrines, and physical factors such as heat or cold and stretcheffects on endothelial membrane. The paracrine regulation ismainly regulated by NO, histamine release and prostacycline.The ventilatory equivalent and physiologic dead space arereduced to normal levels after corrective surgery that eliminatesthe right to left shunts. The application of aerobic exercise postsurgically helps to enhance oxygen uptake. On the whole theexercise increases work capacity of the muscles, increasecardiac output and increase exercise capacity of the individual.

Previous studies have revealed that regular physical activitylike walking is safe, feasible and easy to adapt. Studies havenot revealed about the specific intensity, duration and frequencyof exercises in post-surgical in adult population of ACHDs.

Structured exercise programme is the treatment of choice,though many studies have revealed that regular physical activitycan improve the range of health, very few have emphasized onaerobic exercise capacity and QOL in ACHD individuals. Henceit is necessary to study the influence of graded aerobic exercisein post-surgical adults with acyanotic congenital heart diseaseon exercise capacity and QOL.

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Informed consent was secured from all the patientsparticipated in the study. The study protocol was approved bythe ethics committee of the institute. Moreover, the study wasalso registered under clinical trial registry of India.

The design adopted for the study was prospectiverandomized clinical trail. The course of selection of studysamples, their laboratory/ hospital investigations,physiotherapeutic exercises, data recording etc. were conductedduring a period of 2006 to 2009.

Adult acyanotic congenital heart disease samples weredrawn among those admitted and operated in the cardio thoracicward at the Tertiary Care Centre, Sri Venkateswara Institute ofMedical Sciences, university, Tirupathi, Andhra Pradesh.

In the present study all samples, who were clinically andobjectively diagnosed and selected by cardiothoracic surgeonwere randomly divided into study and control grouppreoperatively by simple randomization method where lotterymethod is the procedure adopted to randomly select thesamples. It was ensured that there was no residual deficit existedafter the surgical correction.


A total of 111(excluding 9 dropout samples) samples, male-39 no. i.e. 35.1%, female- 72 no. i.e. 64.9% were finally selectedfor the investigation. The mean age groups of the samples were28.92 ± 10.98 in the study group. In control group mean age ofthe samples are 28.88 ± 10.38. The control group is representedby 60 samples while the study group consists of 51 samples(with dropout of 9 samples).

The samples with the CHD conditions considered forinvestigation are all of acyanotic heart diseases, atrial septaldefect (ASD) with pulmonary stenosis, ventricular septal defect(VSD), patent ductus arteriosus (PDA), left to right shunts.

The samples with the following CHD conditions wereexcluded from the study are cyanotic heart disease, severepulmonary vascular disease, cardiomyopathy, severeatrioventricular valve regurgitation; exercise induced ventriculararrhythmia, samples with moderate to severe obstructive lesions.

The outcomes measures in the study were BMI (kg/m2),Ejection fraction (%),Nitric oxide (mmol/L), VO2 peak (ml/kg/min) and Quality of life (score).BMI was recorded usingQuetelet index3, Ejection fraction through echo4, Nitric oxideanalysis by Griess method 5, Bicycle ergometer to measure theventilatory oxygen peak uptake (VO2 peak)6 and self assessedhealth related quality of life questionnaire SF-36 form to assesshealth related quality of life7.

Control Group

� The samples were advised to continue the exercises andmedication as per the surgeon and researcher advice. Alog book was given to record their activity and exercisesduring the 12 week period and was reassessed after 12

weeks. The samples were given conventional postoperative physiotherapy care after surgery. Initially thesamples were taught breathing exercises, mobility of upperlimb and lower limb, and progressive walking during in-patient phase and progress the above exercises for theperiod of 12 weeks within the limit of tolerance of thesamples.

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Study Group

� After initial base evaluation samples were prescribedindividualized structured exercise protocol and weremodified weekly as per the individual tolerance. Thesamples were observed for any adverse effect of exerciseduring training and also educated about the sign andsymptoms to terminate exercise. The structured protocolwas prescribed for 12 weeks period and then samples werereassessed for outcome measures.Exercise based cardiac rehabilitation programme with

structured graded aerobic exercise protocols for adult acyanoticCHDs after surgery was implemented. 8 The exercise protocols

with specific intensity, duration and frequency were implementedfrom day 1 of surgery to a period of 12 weeks in a phased manner.The exercise based cardiac rehabilitation is implemented in 3phases.

Data Analysis

All statistical computations have been done using SPSS13.0 version. Data is analyzed with p value <0.001 and powerof the study is 90%. Paired t-test is used to compare mean valuesbetween pre and post tests of each parameter and t test is usedto find out the mean percentage change in the parameters.

Demogaphic information of the subjects (gender wise percentage distribution of subjects in each group)

Study goup (N=51) Control group (N=61)Male(%) Female (%) Male(%) Female (%)38 62 33 67

Comparison of pre and post intervention values of BMI between study and control group

Comparison of pre and post intervention values of all outcomes between study and control group

** Mean Difference between control and study groups is significant at 0.001 level.

parameter Study group Paired t - Control group Paired t- ppre post test pre post test

mean SD Mean SD mean SD Mean SD

BMI 17.573 ± 18.296 ± -6.13 18.432 ± 19.387 ± -7.2 0.0000**3.140 3.269 2.661 2.682

EF 56.420 ± 60.340 ± -10.06 56.970 ± 59.460 ± -4.5 0.0000**7.109 6.403 7.525 6.958

NO 25.220 ± 32.940 ± -20.06 24.620 ± 29.160 ± -14.32 0.0000**8.343 8.700 8.654 8.307

VO2 peak 28.644 ± 43.838 ± -12.32 21.823 ± 30.991 ± -11.90 0.0000**5.406 10.334 6.224 7.958

QOL 48.980 ± 72.280 ± -12.45 46.670 ± 57.930 ± -6.16 0.0000**14.727 8.071 14.205 11.019


90 K Madhavi / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Comparison of pre and post intervention values of EF between study and control group

Comparison of pre and post intervention values of NO between study and control group

Comparison of pre and post intervention values VO2peak between study and control group

91K Madhavi / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Comparison of pre and post intervention values of QOL between study and control group

Mean percent change of various study parameters between control and study group (BMI, EF, Nitric oxide, VO2peak andQOL.)

PARAMETER CONTROL STUDY T-TEST P-VAL

Mean ± SD Mean ± SD

BMI PRE 18.432 ± 2.661 17.573 ± 3.140

POST 19.387 ± 2.682 18.296 ± 3.269 -1.284 0.2020

DIFFERENCE 0.955 ± 1.028 0.724 ± 0.834

(Post – Pre) (5.182%) (4.118%)

EF PRE 56.970 ± 7.525 56.420 ±7.109

POST 59.460 ± 6.958 60.340 ± 6.403 2.978 0.0040**

DIFFERENCE 2.492 ± 2.307 3.920 ± 2.747

(Post – Pre) (4.374%) (6.948%)

NITRIC PRE 24.620 ± 8.654 25.220 ± 8.343

OXIDE POST 29.160 ± 8.307 32.940 ± 8.700 6.521 0.0000**

DIFFERENCE 4.541 ± 2.475 7.720 ± 2.650

(Post – Pre) (18.444%) (30.611%)

VO2PEAK PRE 21.823 ± 6.224 28.644 ± 5.406

POST 30.991 ± 7.958 43.838 ± 10.334 4.296 0.0000**

DIFFERENCE 9.168 ± 6.014 15.193 ± 8.714

(Post – Pre) (42.011%) (53.041%)

QOL PRE 46.670 ± 14.205 48.980 ± 14.727

POST 57.930 ± 11.019 72.280 ± 8.071 4.569 0.0000**

DIFFERENCE 11.262 ± 14.272 23.300 ± 13.225

(Post – Pre) (24.132%) (47.570%)

** Mean percentage change between control and study groups is significant at 0.001 level.

92 K Madhavi / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Mean percent change of BMI between control and study group

Mean percent change of EF between control and study group.

Mean percent change of Nitric oxide between control and study group

93K Madhavi / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Mean percent change of , VO2peak between control and study group

Mean percent change of QOL between control and study group.

Discussion

The result of analysis of the study generally showssignificant improvement in physiological and functionalcharacteristics of the study group over the control groupindividuals. For the sake of convenience, the results of each ofthe outcomes are comparatively evaluated with earlier works.

In the present study, it has been reported that exercisebased cardiac rehabilitation with “unstructured” (control) gradedaerobic exercise in adult ACHD individuals has shown increasedmean value of 18.43±2.66 (pre surgery ) to 19.38±2.66 (afterpost surgery therapy). So also the study group “structured“aerobic exercises have shown an enhanced mean value of BMIfrom 17.57±3.13 (pre surgery) to 18.29±3.26 (after post surgerytherapy). The mean percentage change of BMI values hasdecreased from 5.18 %( control group) to 4.11%(study group).

Earlier studies by Chen et.al (2004)., Manal Kandilet.al(2009) and Karen et.al (2005) 9 supports the above statisticaldata. The reports of the studies are discussed below.

The pre operative adult individuals with acyanotic congenitalheart disease showing mean BMI value of 18.4 in control groupand 17.5 study group suggest growth retardation present inacyanotic congenital heart diseases, presurgically Theunderlying causes may be due to hypoxemia, insufficient calorie

intake, dyspnoea, frequent infections, psychologicaldisturbances, malabsorption or hypermetabolism. Both thegroups of the present study indicated gained weight followingthe surgery. There is a tendency for increase of weight gainafter the surgery due to the reasons of post surgical immobility,less physical activity and tendency for increased intake of food.The weight gain in control group may be due to less physicalactivity than the study group. However, the decrease of BMI inthe study group is due to the implementation of structured aerobicexercises which in turn increases energy expenditure.

Thus the structured graded aerobic exercise in post-surgicaladult acyanotic congenital heart disease regulates BMI andhence forth improves aerobic capacity and QOL.

Exercise based cardiac rehabilitation in individuals of controlgroup (un structured aerobic exercise) with adult acyanoticcongenital heart disease shows significant mean Nitric oxidevalues both with the pre and post therapy (i.e. 24.62±8.65 to29.16±8.30). The structured aerobic exercise / study group ofadult ACHD individuals had shown greater increase in meanpre and post therapy nitric oxide values (25.22± 8.34 to32.94±8.70) than control group. The mean % change in Nitricoxide values between control and study group varies from18.44% to 30.61% .

94

In the present study, the mean EF values shows an increaseof pre therapy level (56.97± 7.52) to post therapy level (59.41±6.95) in the control group. Significant increase is found in meanvalues of EF from 56.42±7.10 to 60.34 ± 6.40 from pre surgeryto post surgical levels in study group. Significant increase isfound in mean % of EF from 4.37 %( control group) to 6.94%(study group).

This shows that adults with acyanotic CHD have a reducedfunctional capacity as compared to the normal individuals. Thisphenomenon appears to be associated with right ventricular andpulmonary abnormalities.

Rainer Hambercht et al (1995) reported that stable chronicheart failure samples benefit from ambulatory cardiacrehabilitation programs similar to those prescribed for sampleswith coronary heart disease. 11 Even samples with severedepression of left ventricular performance are benefited fromtraining-induced increase in aerobic capacity of peripheralmuscles. Cardiac output increases significant change in maximalcardiac output with significant correlation with the change inpeak oxygen uptake.

Very few studies have used ejection fraction to measurethe cardiac output. The cardiac rehabilitation programs in varioustypes of CVD have shown positive influence on the EF. Theincrease in EF is associated with increase in exercise capacity.The structured aerobic exercise increases ejection fraction. Thisin turn increases exercise capacity in post surgical adult CHDpopulation. The values of the study in the present shows that it.

The mean VO2peak values of pre and post-therapy ofcontrol group has increased from 21.82±6.22 to 30.99±7.95.where as in the study group mean values of VO2peak showsphenomenal increase in pre therapy level to post therapy levelfrom 28.64±5.40 (pre) to 43.83±10.33(post).

The mean % of change of VO2peak is statistically significantin study group (53.04%) unlike in the control group (42.01%).

Our study showed a significant improvement incardiopulmonary capacity in post surgical ACHD population,which concurs with the finding of the Helber et al (1997). Hereported among pre operative adult samples with non restrictiveASD there was some improvement seen at 4 months afteroperation, with complete restitution to normalcy., 10 years aftershunt closure.12 Further Fredrikson et al (2001) revealed thatsamples with fontan circulation had shown greatly diminishedvalues of aerobic capacity but with an early surgical procedurethere is improvement in VO2 peak. A number of studies havebeen conducted on exercise capacity of adult ACHD populationand concluded that the exercise capacity which diminishes pre-operatively, is enhanced significantly with exercise protocols.

Hence, exercise capacity increases after surgical closureof the defect. With corrective surgery, there is an increase in theoxygen extraction of muscles and there by cardiac output andexercise capacity is enhanced. Therapeutic training contributesto gross increase of aerobic capacity in post surgical adultACHD population.

The mean pre and post therapy QOL value in control groupvaries from 46.67 ± 14.20 to 57.93 ± 11.01 respectively. Whereasthe corresponding mean values of study group varies from48.98±14.72 to 72.28±8.07 (post operatively). The study groupshows highly significant changes unlike the control group.

The mean % change from 24.13% to 47.57% of control tostudy groups is found to be statistically significant.

Lane et al (2002) reported that samples with inoperable orcyanotic conditions seemed surgically cured, had the poorestquality of life. 13They had significantly poorer levels of physicalfunctioning and overall general health perception than similarlyaged people in the general population. This observationcorrelates with the finding of our study.

Hager et al (2005) revealed that exercise tests and QOLinstruments should be used together to get an appropriateoverview of health status of patient with congenital heart disease.14 Jaspal S. Dua (2007) observed that limited data is available

on the physical activity levels and attitude to exercise. 15 Thereare also studies that shows improvement in quality of lifeimproves with increased physical activity levels.

The foregoing comparative discussion on physical (BMI),physiological (NO & EF) and functional parameters [VO2peak]has enlightened that there is a gross improvement in the abovevalues after implementation of graded aerobic exercise protocolin study group. The increase in physical and physiologicalparameters has overall enhanced QOL among ACHD samplesof study group.

Conclusions

The findings of the study shows % change/improvement inphysical (BMI), physiological (NO and EF) and functionalcharacteristics before and after cardiac rehabilitation therapyamong post surgical ACHD individuals.

In a nutshell, it has to be admitted that structured gradedaerobic exercise has grossly improved the Exercise Capacityand Quality of Life in the post surgical adult acyanotic CongenitalHeart disease individuals.

References

1. Fauci , Braunwald, Kasper , Hauser, Longo, Jameson:Harrison’s principles of internal medicine. Mc GrawHill 17th

ed. ;229: 1458-1465.2. Julien . I. E Hoffman, MD, FACC, Samuel Kaplan, MD,

FACC. The incidence of congenital heart diseases.J.Am.Coll.Cardiol. 2002;39:1890-1900.

3. Jackson AS et al. prediction of functional aerobic capacitywithout exercise testing; journal of medicine and sciencein sports and exercise. 1990;22:863-873.

4. Harvey Feigenbaum, Feigenbaum’s echo cardiography. 6th

ed .Lippincott 2005; chapter 6 : 141-146.5. Green LC , Wagner DA, G Glogowski J , Skipper PL,

Wistinok JS, Tannenbaum SR. Analysis of nitrite and (15N)nitrate in biological fluids. Anal Biochem 1982; 126;131-8.http://www.promega .com.

6. YMCA submaximal ergometer test. Exrx.net/testing/YMCACycleTest.html

7. SF-36 ® Healh survey update by John E. Ware, Jr., Ph.D.http://sf-36.org/tools/sf-36.shtml.

8. American college of sports medicine Guidelines 2006.9. Karen E. Foster- Schubert, Anne Mc Tiernm, R. Scott Frayo,

Robert S. Schwartz, et al Human plasma Ghrelin levelsincrease during one year exercise programme. J. ClinEndocrinol.Metabolism:2005;90:820-825.

10. Bronwyn. A. Kingwell. Nitric oxide mediated metabolicregulation during exercise: effects of training in health andcardiovascular disease. FASEB Journal 2000;14;1685-1696.

11. Rainer Hambrecht et al. physical training in patients withstable chronic heart failure: effect on cardiorespiratoryfitness & ultra structural abnormalities of neck muscles.J.Am. Coll. Cardiol. 1995;25:1239-49.

12. Helber et al Atrial septal defect in adults andcardiopulmonary exercise capacity before and 4 monthsand ten years after defect closure. J.Am. Coll. Cardiol.1997;29:1345-50.

13. DA Lane , GYH Lip, TA Millane Quality of life in adults withcongenital heart disease. Heart 2002; 88:71-75.

14. A. Hager et al. comparison of health related quality of lifewith cardiopulmonary exercise testing in adults andadolescents with congenital heart diseases. Heart 2005;91:517-520.

15. Jaspal S. Dua, Asley R. Cooper, Kenneth R. Fox, AlanGraham stuart. Physical activity levels in adults withcongenital heart disease. European journal ofcardiovascular prevention and rehabilitation.2007;14:287-293.


95Kusumalatha Nookala / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Efficacy of Mirror Therapy on Motor Recovery of Hand Functionsin Sub Acute Stroke Individuals-a Randomized Controlled TrialKusumalatha Nookala1, Srikumari Vadlamudi2

1,2Assistant Professor, Sri Venkateshwara Institute of Medical Sciences, Alipiri Road,Tirupathi-517501,Andhra Pradesh

Abstract

Aim of the Study

The aim was to find out the efficacy of mirror therapy(congruent visual feedback from the moving non-paretic hand)on motor recovery of paretic hand functions in sub acute strokeindividuals.

Objective

1. To analyze the motor recovery of hand functions in subacutestroke individuals after mirror therapy.

Design

• Randomized controlled experimental study.

Setting

• Outpatient clinic, neurology department and general wardsin SVIMS.

Participants

• Total number of subjects 30.• 15 in experimental and 15 in control group.

Interventions

The treatment session was 6 days a week, 30 minutes aday, for 6weeks excluding the time for conventional program.The conventional program consisted of physiotherapy likepassive movements, active movements, strengtheningtechniques for the same period.

Mainoutcome Measures

1. Motor assessment scale(hand movements)2. Modified ashworth scale for wrist flexors..3. Brunnstrom stages of motor recovery for hand.

Results

Comparison was made between control and experimentalgroups at 0.05 level of significance. Mann –Whitney U statisticwas applied to compare and results were found insignificant inASHWORTH parameter (p= 1.00 NS) and significant resultsare observed for MAS (p < 0.05) and BRUNSTORM (p<0.05)parameters.

Conclusion

Mirror therapy along with conventional rehabilitation(congruent visual feedback) led to greater improvement in themotor recovery of hand functions in sub acute stroke subjectsthan sham therapy.

Introduction

Stroke is defined as a rapidly developing clinical signs offocal disturbance of cerebral functions lasting more than 24 hoursor leading to death with no appropriate cause other than that ofvascular origin.1

Stroke is the third leading cause of death world wide. AWHO study in 1990 quoted incidence mortality due to stroke inIndia to be 73/100,000 per year. The incidence ofcerebrovascular disease was found to be 2/1000 population perannum and 4/1000 population per annum in people aged 45 to84 years.2

A stroke causes disturbed neural command generation inthe sensory motor cortex is impaired arm and hand motorfunction. Optimal restoration of arm and hand motor function isessential for stroke subjects in order to independently performactivities of daily living. The paretic upper limb is a common andundesirable consequence of stroke that increases activitylimitation.16 Mirror therapy is a simple, inexpensive and mostimportantly, patient directed treatment and using of unaffectedlimb.5

Mirror therapy is based on mirror neurons present in thepre-motor cortex. Which are tiny neurological structures that firewhen we perceive an action and take it. These mirror neuronswere discovered in mid 1990’s by the scientists at the Universityof Parma in Italy.27 Later Marco Iacoboni, a neuroscientist atUniversity of California led to the discovery’s impact onpsychology. The major implication of mirror neurons is that thesame brain region that controls action also supports perception.6

The principle of exciting mirror neurons is based on motorimagery, which means increase in the excitability of thehomologous motor system pathways when uni-manualmovements are performed.28

The physiology of mirror neurons is based on stimulationthrough simulation or motor imagery.7 Motor imagery is themental representation of movement without any bodilymovement. Mirror therapy consists of evaluation of handimpairments and functional limitations of stroke individuals.Guided training sessions of mirror therapy to improve theimpaired hand movement using unaffected extremity in orderto improve the motor function of the hemi paretic arm14. Hence,in order to improve the hand functions of the hemi paretic arm,mirror therapy is used to evaluate the motor recovery of thehand in sub acute stroke individuals.


Thirty subjects were recruited from SVIMS who wereprovided with informed consent. and were grouped in two groups:Experimental (mirror) group and control (sham) group, of 15each by random number allotment.

Study Design

Randomized controlled experimental study.

Sample Collection

Total number of subjects 30, 15 in experimentalGroup and 15 in control group.

96

Gender : Only maleStroke duration : Three to nine months of post stroke18

Materials : A plane mirror (35 x 35cm) A table and a chair with back support.

Modified ashworth scale for wristflexors11

Motor assessment scale (handmovements) 10

Brunnstrom stages of motor recoveryfor hand22

Study duration : 6 weeks.

Inclusive Criteria

• Subacute(3 to 9 months) stroke individuals who had a firstepisode of unilateral stroke with hemi paresis during theprevious 3 to 9 months.18

• Subjects of age group between 45 to 65 years.• Subjects who are able to understand and follow simple

verbal instructions.• Subjects with right middle cerebral artery stroke (ischemic)19

• Brunnstrom stages for hand between 2 to 4 grades for boththe groups

• Modified ashworth scale for wrist flexors between 1 to 2grades for both the groups.11

• Motor assessment scale for hand movements between 1to 3 grades for both the gropus.10

• Medically stable.

Exclusive Criteria

• Perceptual and cognitive deficits.• Subjects who are not co-operative• Subjects with visual impairments• Acute and chronic stroke individuals• Subjects with recurrent episodes of stroke• Subjects subjected to no other disorders (traumatic,

neoplastic)• Subjects with age group above 65 years.• Subjects with sensory deficits.• Musculoskeletal problems like contractures, pain &

subluxation .

Methodology

Subjects are randomly assigned to Experimental Grouptreated with mirror therapy and conventional therapy and ControlGroup treated with sham therapy and conventional therapy.

Subjects’of both the groups were graded on the basis ofthe outcome measures i.e. Modified ashworth scale for wristflexors, Brunnstrom stages of motor recovery for hand, Motorassessment scale ( hand movements).

The treatment session was 6 days a week, 30 minutes aday, for 6 weeks excluding the time for conventional program.The conventional program consisted of physiotherapy likepassive movements, active movements, strengtheningtechniques for the same period.

During the mirror therapy subjects were seated close to atable on which a mirror (35 x 35 cm) was placed vertically. Theinvolved hand was placed behind mirror i.e. the non reflectiveside and the non-paretic hand in front of the reflective side ofthe mirror.

The practice consisted wrist flexion and extension followedby finger flexion and extension movements of non-paretic hand,while subjects looked into the mirror, watching the image of theirnon-involved hand, thus seeing the reflection of the handmovements projected over the involved hand. Subjects couldsee only the non-involved hand in the mirror. During the sessionsubjects were asked to try to do the same movements with paretichand while they were moving the non paretic hand.25

The control group performed the sham therapy, whichincluded the same exercise for the same duration and the sameconventional therapy but used the non-reflected side of the mirrorin such a way that the paretic hand was hidden from sight.

After 6 weeks duration the outcome measures i.e. Modifiedashworth scale for wrist flexors, Brunnstrom stages of motorrecovery for hand, Motor assessment scale( hand movements)were again taken from both the groups.

Mirror Therapy

Sham Therapy

Results and Analysis

• Statistical analysis was performed to observe thesignificance between pre and post values of the outcomemeasures. SPSS16.0 package and MS –EXCEL whereused to carryout the computations. The entire data is carriedout at 0.05 level.

• Of the 30 subjects 15 were randomized in to experimentalgroup (mirror therapy) and the other 15 were randomizedin to control group (sham therapy). Of these all 30completed the entire study protocal. The outcomemeasures of the study were Modified Ashworth scale, Motor

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Assessment scale and Brunnstrom stages of motorrecovery.

• In table 1 the pre and post values of experimental groupwere compared for each parameter using Wilcoxon signedranks test. The results were found to be highly significant

Table 1: Wilcoxon Signed Ranks Test: Experimental Group

N Mean Standard Deviation Z - value Sig (2-tailed)

ASHWORTH_PRE 15 1.53 0.5161.732 0.083NS

ASHWORTH_POST 15 1.33 0.488

MAS_PRE 15 2.33 0.8163.520 0.000*

MAS_POST 15 3.73 1.033

BRUNNSTROM_PRE 15 3.20 0.8623.508 0.000*

BRUNNSTROM_POST 15 4.93 0.884

* Represents significance at 0.05level.

in motor assessment scale and brunnstrom stages of motorrecovery and found insignificant in modified ashworth scaleat 0.05 level.

• Pre and post values of all the parameters in experimentalgroup

In table 2 the pre and post values of control group werecompared for each parameter using Wilcoxon signed rankstest.Modified ashworth scale was found to be insignificant at 0.05

TABLE 2: Wilcoxon Signed Ranks Test: Control Group

N Mean Standard Deviation Z - value Sig (2-tailed)

ASHWORTH_PRE 15 1.60 0.5071.732 0.083NS

ASHWORTH_POST 15 1.40 0.507

MAS_PRE 15 2.13 0.8343.071 0.002*

MAS_POST 15 3.07 1.033

BRUNNSTROM_PRE 15 3.13 0.8342.810 0.005*

BRUNNSTROM_POST 15 3.87 1.060

* represents significance at 0.05level.

level whereas the other 2 motor assessment scale andbrunnstrom stages of motor recovery were found highlysignificant at 0.05 level.

Pre and post values of all the parameters in control group


Fig. 1:

98 Kusumalatha Nookala / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Table 3: Comparison of all the parameters in experimental and control groups (Mann Whitney U test)

GROUP N Mean Rank Mann-Whitney Sig (2-tailed)U - statistic

ASHWORTH_DIFF CONTROL 15 15.50112.500 1.000NS

EXPERIMENTAL 15 15.50

MAS_DIFF CONTROL 15 12.80 72.000 0.039*


BRUNSTROM_DIFF CONTROL 15 10.43 36.500 0.001*


‘*’ represents significance at 0.05 level

Analysis has been carried out by taking the differences ofpre and post of control and experimental groups and comparisonwas made between the two groups at 0.05 level of significance.Mann –Whitney U statistic was applied and results were foundinsignificant in ASHWORTH parameter (p= 1.00 NS) and

significant results are observed for MAS (p < 0.05) andBRUNSTORM (p<0.05) parameters.

Using the mean ranks of all parameters in control andexperimental Bar graph representation was made and is shownbelow.

Figure-2

Figure 1 and 2 represents the mean response of the three parameters for experimental control group

It is evident that motor assessment scale and brunnstrom stages of motor recovery for hand post mean responses were significantlydiffering at 0.05 levels.

99Kusumalatha Nookala / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Discussion

The purpose of the study was to find the efficacy of mirrortherapy compared to sham therapy on hand functions of upperextremity in sub acute stroke patients. This study shows thatmirror therapy is more beneficial in motor recovery and handrelated functioning than sham therapy after a post treatment for6 weeks.However there was no effect on spasticity.

The underlying principle is that movement of the affectedlink can be stimulated via visual cues origin from the oppositeside of the body.24 Hence, it is thought that this form of therapycan prove useful in stroke individuals who have lost movementof an arm or leg including those who have had a stroke earlier.The parameters taken in the study are Modified ashworth scale11,Brunnstrom stages of motor recovery and Motor assessmentscale. 10Prior to the exercise program the scores of the abovethree parameters were noted and after the study span i.e. aftersix weeks scores were again noted.

At the end of six weeks it was found that according to table-1 the scores of motor assessment scale and brunnstrom stagesof motor recovery were found to be highly significant. However,the scores were insignificant in modified ashworth scale.

Several underlying mechanisms, for the effect of mirrortherapy on motor recovery after stroke have been proposed, ofthem Altschuler et al. (1999) suggested that the mirror illusionof a normal movement of the affected hand may substitute fordecreased proprioceptive information.5 There by helping torecruit the premotor cortex and assisting rehabilitation throughan intimate connection between visual input and premotor areas.

From table-2 modified ashworth scale scores were foundto be insignificant where as the scores of motor assessmentscale and brunnstrom stages of motor recovery were found tobe highly significant. Stevens and Stoykov (2003)suggested thatmirror therapy related motor imagery and that mirror createsvisual feedback of successful performance of the imaginedaction with the impaired limb. Motor imagery itself has proven tobe potentially beneficial in the rehabilitation of hemiparesis.9

According to table-3,where mean differences of all the threeparameters in both the groups were compared , significant resultswere observed for MAS (p < 0.05) and BRUNSTORM (p<0.05)parameters.

According to Carson (2005) studies when the non pareticlimb engaged during motor training crossed facilitatory drive fromthe intact hemisphere will give rise to increase excitability in thehomologous motor path way of the paretic limb, facilitatingrecovery of function.15

Stimulation through simulation mechanisms based onincreased visual or mental imagery feedback, which is anotherpossible mechanism for the effectiveness of mirror therapy mightbe bilateral arm training.7

The only drawback for this study was the unavailability offMRI results in order to prove the mirror neuron excitability forbetter outcome.17

Hence, the improvement in the motor recovery of hand inthe experimental group could be attributed to mirror therapywhich is based on motor imagery. Rothgangel A, De Bie RA etal,(2006) found that during movement observation using mirrorvisual feedback a significant increase in cerebral blood flow wasobserved in the ventral motor cortex, further more activation inthe visual cortex was lateralized opposite to the seen hand usingfMRI.19

In control group there was improvement in the outcomeparameters due to repetitive goal oriented activities and alsodue to the conventional therapy. Hilde Feys, Willy De Weerdt etal, (2004) said that repetitive sensory motor training of the armduring the acute phase after a stroke resulted in a clinicallymeaningful and long lasting effect on motor function. The effectcan be attributed to early repetitive and targeted stimulation.20Thelimitations of this study are small sample and shorterduration.This study could be further analyzed by measuring

the excitability of mirror neurons using functional brain imagingpost mirror therapy.30 and to investigate on stroke individualswith cognitive deficits using as home treatment.

Conclusion

Mirror therapy along with conventional rehabilitation(congruent visual feedback) led to greater improvement in themotor recovery of hand functions in sub acute stroke individualsthan sham therapy.

References

1. J N Panicker, N. Thomus, K. Pavithran, D. Nair, P.S. Sarma.Morbidity predictors in Ischemic stroke neurology India2003; 51:49-51.

2. Bhalla A Gupta OP, Gupta SB, Predicting mortality in strokeneurology in India, 2002; 279-281.

3. Susan B O’sullivan & Thomas J Schmitz .PhysicalRehabilitation Assessment and treatment, 4th edition.Jaypeebrothers medical publishersp: 2001; 519-565.

4. Pomeroy VM, et al .The potential for utilizing the “mirrorneurone system” to enhance recovery of the severelyaffected upper limb early after stroke:a review andhypothesis. Neurorehabili Neural Repair2005;19:4-13.

5. Altschuler EL, Wisdom SB,Stone et al.Rehabilitation ofhemiparesis after stroke with a mirror. Lancet 1999; June11;353:2035-6.

6. Macro lacoboni, Istvan Molnar, szkacs, Vittoria gallese et.al:grasping the intention of others with ones own mirror neuronsystem, vol 3; issue 3; March 2005.

7. Johnson-Frey, Stimulation through simulation? Motorimagery and functional reorganization in hemiplegics strokepatients. Brain cogn, 2004; 55; 328-331.

8. Ramachandran VS. Mirror neurons help in imitationlearning which are the driving force for the humanevolution:Edge CG May 29, 2000.

9. Stevens JA, Phillips Stoykov ME. Using motor imagery inthe rehabilitation of hemiparesis. Arch Phys Med Rehabil2003;84:1090-2.

10. Poole JL, Whitney SL, Motor assessment scale for strokepatients: concurrent validity and interrater reliability, ArchPhys Med Rehab, 1998, 69:195-197.

11. Allison Drashear et.al, Inter and intrarater reliability of theAshworth Scale in Subjectswith upper limb post strokespasticity; Arch Phys Med Rehab, Vol. 83, Oct.2002; 1349-1354.

12. Patricia M Davies, “Starting again”. First edition 1994;springer – verbag publisher.

13. Rizzolatti et al, Discovery “mirror neurons.” ExperimentalBrain Research 1992; 91,1, 176–180.

14. Garry MI, et. Al, Mirror,mirror on the wall: viewing a mirrorreflection of unilateral hand movements facilitates ipsilateralM1 excitability.Exp Brain res 2005;163:118-22.

15. Carson RG, Neural pathways mediating bilateralinteractions between the upper limbs . Brain Res Rev2005;49:641-62.

16. John w. krakaver, Arm function after stroke; from physiologyto recovery.Seminars in neurology 2005;25,4.

17. Luciano Fadiga and Lalia Craighero: Electro physiology ofaction representation, journal of clinical neuro physiology;June 2004; 21; 6.

18. Steven L. Wolf et al, Effect of Constraint-InducedMovement Therapy on Upper Extremity Function 3 to 9Months After Stroke.Journal of American medicalassociation. November1:vol 296 no.17 2006 .

19. Rothgangel et al; The Role of the Mirror Neuron System inRehabilitation with Mirror Therapy following Middle CerebralArtery Infarction - a pilot fMRI study .German medicalscience:sept 2006.

100

20. Hilde Feys PT., PHD; Willey De Weerdt, Geert Verbeke etal. Early and repetitive stimulation of the arm cansubstantially improve the long term outcome after stroke, a5 year follow up study of a randomized trial: Stroke 2004;35:924.

21. Giacomo Rizzolatti and Laila Craighero: the mirror neuronsystem, March 5, 2004.

22. Welmer AK.Widen Holmqvist L.Sommerfeld DK:Hemiplegiclimb synergies in stroke patients.Am J phys Med Rehabil2006;85:112-119.

23. Erhan Ozton Missuo Kawato, Michael Arbib: Mirror neuronsand imitations: a computationally guided review, Neuralnetworks 2006; 35; 254–271.

24. Manuel Cabido Lopes, Jose Santos Victor: Visual learningby imitation with motor representations. IEEE Transactionson Systems Man and Cybernetics 2005; 35, 3, 438-449.


25. Timothy J. Carroll, Robert D. Herbert, Joanne Munn et al:Contra lateral effects of unilateral strength training: evidenceand possible mechanisms. J Appl Physiol 2006;101: 1514-1522.

26. Rosen B, Lundborg G.: Training with a mirror in rehabilitationof the hand. Journal of Plastic and Reconstructive Surgeryand Hand Surgery2005; 39, 2, 104 – 108.

27. Shmuelof L, Zohary E: Watching others actions: mirrorrepresentations in the parietal cortex. The NeuroscientistDec 2007; 13, 6, 667-673.

28. Pascale Touzalin-Chretien and Andre Dufour: Motor CortexActivation Induced by a Mirror: Evidence From LateralizedReadiness Potentials, April 27, 2008.

29. Kenjifukumara et.al, International journal of neuro science:July 2007; 117.

101

Effect of Unilateral and Bilateral Auricular Acupuncture Like TENSon Pain ThresholdMalik Manoj1, Kaur Jaspreet2

1,2Assistant Professor, Deptt. of Physiotherapy, GJU S& T, Hisar-125001

Malik Manoj / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Background

Pain, although a protective mechanism of our nervoussystem often prevents treatment of accompanying or underlyingdisorder and therefore it is imperative to attain analgesia. .Various modalities are used by physical therapists to relievepatient from pain. TENS is one of the most widely used modalityby physical therapists for attaining analgesia.

Methods

This experimental trial investigated the effect of unilateraland bilateral auricular acupuncture like TENS on pain thresholdin sixty young adults. Subjects were randomized to either ofthree groups namely:- Group 1(Bilateral application of TENS),Group 2 (Unilateral application of TENS), and Group 3 (control- NO TENS group). Low frequency TENS was applied onauricular acupuncture points for 45 secs on Group 1&2.Readings for pain threshold were taken before and aftercompletion of TENS treatment.

Results

There was a statistically significant difference in painthreshold values of auricular TENS group as compared to controlgroup on comparison with one – way ANOVA (F=35.273). Onpair wise comparison using Duncan’s new multiple range test,statistically significant differences were found (p<.05) betweenthe pain threshold changes between group three (control group)as compared to group 1( bilateral TENS group) and group 2(unilateral TENS group).However, no significant difference wasobserved between mean pain threshold changes of group 1and 2.

Conclusion

Auricular application of Acupuncture TENS as a part ofphysiotherapy treatment significantly increases pain thresholdwhether applied unilaterally or bilaterally.

Key Words

Pain, TENS, Auricular Acupuncture.

Address for correspondence:Dr. Manoj MalikM.P.Th. (NEUROLOGY), MIAPH. No.-103, Sector –13, Part IIHisar, Haryana.PIN: -125001Email: - [email protected] No.: - 09896221262

Introduction

Throughout the ages, pain has had a variety of meaningsto those experiencing it and those seeking to alleviate it1. Variousmodalities are used by physical therapists to relieve patient frompain. TENS is one of the most widely used modality by physicaltherapists for attaining analgesia , it is application of pulserectangular currents via surface electrodes. TENS is anoninvasive and nonaddictive treatment for pain used by manyphysical therapists. Many clinical studies have reportedsignificant decrease in pain following application of high intensitylow frequency TENS2-3. Low frequency-high intensity TENSprovides long lasting pain relief in many clinical situations4-9 Lowfrequency high intensity TENS applied to somatic acupuncturepoints is called acupuncture like TENS10. It is defined as theinduction of forceful but non-painful phasic muscle contractionsat myotomes related to the origin of pain7,8,11,12. The purpose ofAL-TENS is to selectively activate small diameter fibers (A&)arising from muscles by the induction of phasic muscle twitches.Thus TENS is delivered over motor points to activate A (alpha)efferents to generate muscle twitches so bursts of pulses areused7. Yi et al have presented the most direct evidence to datethat acupuncture analgesia is mediated by increased productionof serotonin. He stimulated conscious rabbits with acupunctureneedles while measuring serotonin from cerebrals ventricles andfound that for over half of the 18 experimental rabbitsacupuncture stimulation produced a simultaneous increase inanalgesia and in central serotonin13.

Acupuncture points on auricle of the ear are sometimesthe sites for acupuncture like TENS. Oliveri et al14 and Krauseet al15 showed that stimulation of acupuncture points on auricleor auricolotherapy also is used for pain relief and also showedthat low frequency high intensity TENS applied to appropriateauricular points increased experimental pain threshold in healthysubjects. So, the main aim of study was to find effect of auricular,acupuncture like TENS on pain threshold. The Researchhypothesis taken were a) pain threshold measured at wrist ofsubjects with unilateral and bilateral auricular TENS will besignificantly greater than pain threshold of control group b)bilateral auricular TENS treatment will significantly increase painthreshold in comparison of unilateral auricular TENS.


Electricity as method of pain relief has been used fromancient times. Around 2500 BC, Egyptians used electrogenicfish to treat ailments 18 Its popularity declined in nineteenthcentuary , but later in 1965 Melzack and Wall reawakened theinterest in use of electricity . Melzack and Wall proposed thattransmission of noxious information could be inhibited by activityin large diameter peripheral afferents or by activity in paininhibitory pathway descending from the brain19 Study done byAlbere J.A.Koke, Jan S.A.G. Schouten et al on 180 subjectsfound that pain severity decreased between baseline and posttreatment within all groups and types of TENS, but there was nodifference between different types of TENS. As few studiesindicate that TENS not only decreases pain but also increases

102

pain threshold20,21 Further studies were done to find out if TENSgiven on auricular acupuncture points was of any benefit to thepatient. Auricular acupuncture is a form of alternative medicinebased on the idea that the ear is a microsystem with the entirebody represented on the auricle, the outer portion of the ear.Ailments of the entire body are assumed to be treatable bystimulation of the surface of the ear exclusively. Similar mappingsare used in reflexology and iridology. These mappings are notbased on or supported by any medical or scientific evidence22,23

Study done by Anthony G Longobardi, Jo Ann Cheryl J Knowles,James R Jackson on 15 subjects to determine the effectivenessof auricular acupuncture like transcutaneous electrical nervestimulation on pain, concluded that there was significant painreduction after application of high intensity, low TENS onauricular acupuncture points24 Auriculotherapy has been effectivein treating variety of conditions, but its primary use is for painrelief24 Paris and co-workers reported that auricular TENS , inconjunction with traditional physical therapy and electicalstimulation of certain body loci, decreased both pain andrehabilitation time in patients with ankle inversion sprains2. Thereis a lot of scope to research a suitable method of painmanagement , the popular pain management methods like useof NSAIDS, opiods and surgeries like rhizotomy, althougheffectively relieving pain, have many side effects. Thus requiringthe need for alternative methods for pain relief. Research onauricular acupuncture can open the avenues of a pain relieftechnique which is non invasive, non addictive, and moreover ithas no side effects and very few contraindications.

Methodology

Design

Experimental Study Design.


Sample

Sample consisted of Sixty young adults (38 Females & 22Males) recruited from T.D.T.R.Institute of Physiotherapy andRehabilitation Campus, Yamunanagar.

Inclusion Criteria

a Age Group between 18-22 years.b Healthy young adults (Males and Females) without any

neurological deficit.

Exclusion Criteria

a Subjects with pacemakers, metallic implants, rods, artificialjoints or any other surgical implants.

b Pregnant Females.c Subjects with altered pain perception,skin infection.d Subjects with any psychiatric or psychological problem.e Subjects under any medication.

Method of Selection

Subjects were thoroughly evaluated and those meetinginclusion and exclusion criteria and willing to give consent toparticipate in the study were included in the study. The subjectswere then randomly allocated to either of three groups: - Group1(Bilateral application of TENS), Group 2 (Unilateral applicationof TENS), and Group 3 (control - NO TENS group).

Instrumentation for Data Collection

a Tens – Enraf Nonius B.v. (Ens 911) (Fig.1)b Phyaction Guidance E – Gymnauniphy N.v. (FIG.2)

103

Variables

a Independent Variables: - Unilateral and Bilateral AuricularAcupuncture TENS.

b Dependent Variables: - Pain Threshold.

Procedure

Ethical approval was obtained from the institution.Participants were explained about the purpose and nature ofstudy and each subject signed an informed consent form beforeparticipating. At the time of study no subject reported with anyusage of pain relieving drugs or alcohol 24 hrs before study.


Fig. 1: Pain Threshold Measurement

Fig. 2.A: AURICULAR POINT (Ear Shenmen)

Fig.2.B: AURICULAR POINT (Dermis)

Protocol for TENS Therapy

a. Pain Threshold Measurement

Pain threshold was measured with Phyaction. Carbonrubber electrodes were used, intensity was as much as patient’stolerance. Valcro straps were used to keep electrodes in place.Stimulus consisted of rectangular surge current of 100 Hzfrequency and 5 msec duration. Dispersive electrode was placedbehind the subject neck from the level of 7th cervical vertebraand upper thoracic vertebra, while stimulation was applied onskin overlying volar surface of distal end of radius (FIG. 1).Subjects were allowed to feel the current before measurementto familiarize them with the sensation. Intensity of stimulus wasincreased systematically stopping every 0.1 msec, subjects wereasked to report verbally the moment they felt any electric currentand then the moment they felt painful pinprick sensation. Theintensity at which they felt pin prick was recorded threeconsecutive times and the mean threshold value for each subjectwas recorded. Pain threshold measurements were measuredat wrist in all subjects at two time intervals: - before treatment(PRE Treatment) and after (POST Treatment).

b. TENS Therapy

The dispersive electrode of auricular TENS was placed onsubject’s left hand. Any jewellery was removed by subject. Anauricular stimulation point was noted using acupuncture chartand was applied via probe electrode (FIG 2A&B). Frequencywas set on 2 Hz. Each subject was asked to report verbally thefirst moment stimulus was felt by saying feel it. The stimuluswas increased until the subject’s tolerance reached tolerant limit.Each auricular point was stimulated for 45 sec, with the intensityas high as subject’s tolerance. High intensity low frequency TENSwas given on different auricular points. Group 1 receivedbilaterally, group 2 received unilaterally, group 3 subjects restedon treatment table for 10 min maximum time required to completean auricular TENS treatment. All subjects were given TENStherapy, with each treatment session of 10 minutes duration.The total time taken for recording the data was 1 week.

Data Analysis

Descriptive statistics was calculated for pre treatment andpost treatment measurements for change in mean pain thresholdfor each group. One-way ANOVA (analysis of variance) wasused. Pair wise comparison between groups was made withDuncan’s new multiple range test. An alpha level of .05 wasselected for all tests. SPSS 11.0 version software was used fordata analysis.

Results

Descriptive characteristics regarding sex and age areshown in Table 1. Group 1 had 13 females, 07 males with meanage of 21.83. Group 2 had 13 females, 07 males with mean ageof 19.61 while group 3 had 08 males, 12 females with meanage of 19.61.

The mean pain threshold values for Group 1 receivingBilateral TENS therapy PRE and POST treatment were 2.0 and2.78, respectively. For Group 2 receiving Unilateral TENS, themean values PRE and POST treatment were 2.20 and 2.94respectively. The pain threshold values for Group 3 (controlgroup) were 2.044 and 2.047, PRE and POST treatment,respectively (TABLE 2 and GRAPH 1).

Group 1 receiving Bilateral TENS had an increase in Meanpain threshold values by 0.78.In Group 2, receiving unilateralTENS the Mean pain threshold increased by 0.74. In Group 3,Mean pain threshold increased by only 0.003 (Table 2 And Graph2).

104 Malik Manoj / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Table 1: Descriptive Statistics

S.No Characteristics Group 1 Group 2 Group 3N=20 N=20 N=20

1. No. of female subjects 13 13 082. No. of male subjects 07 07 123. Mean Age 21.83 19.61 19.61

The percentage increase in Mean pain threshold values ofGroup 1, 2 and 3 compared to baseline was by 39%, 33.6% and0.14% respectively (TABLE 2 AND GRAPH 3).

On comparing Mean pain threshold values with One -WayANOVA statistically significant difference was found betweengroups. Therefore a statistically significant difference existed

Descriptive statistics regarding pain threshold measurements and average initial pain threshold of groups, final pain thresholdand mean increase pain threshold with pain threshold ranges are given in Table 2.

Table 2: Mean pain threshold measurements

Group 1, Bilateral points (n=20) Mean pain threshold RangePretreatment 2.0 1.46-3.2Post treatment 2.78 2.2-4.2Change 0.78 0.26-1.47Percentage Increase 39%Group 2, Unilateral points (n=20) Mean pain threshold RangePretreatment 2.20 1.46-3Post treatment 2.94 2.0-4.53Change 0.74 0.14-1.53Percentage Increase 33.6%Group 3, Control group(n=20) Mean pain threshold RangePretreatment 2.044 1.4-3Post treatment 2.047 1.4-3.13Change .003 0.27-0.2Percentage Increase 0.14%

Table 3A: Difference in pain threshold - ANOVA

95% confidenceinterval for MeanLower Upper

S.No N Mean Std.deviation Std.error bound bound Minimum Maximum

1. 20 0.7470 0.42383 0.09477 .5486 .9454 .06 1.4712. 20 0.7378 0.33962 0.07594 .5788 .8967 .14 .533. 20 0.0025 0.12435 0.02780 -.0557 .0607 -.27 .201

Total 60 0.4958 0.47297 0.06106 .3736 .6179 -.27 .53

Table 3B: Difference in pain threshold - ANOVA

Sum of df Mean F Sig.square Square

Between group 7.300 2 3.650 35.273 .000Within group 5.898 57 .103Total 13.198 59

Table 4: Multiple comparison

95% confidence interval(I)GROUP (J)GROUP Mean diff (I-J) Std.error Sig Lower bound Upper bound

1 2 -.1460 .10698 .178 -.3602 .06823 .5445* .10698 .000 .3303 .7587

2 1 .1460 .10698 .178 -.0682 .36023 .6905* .10698 .000 .4763 .9047

3 1 -.5445* .10698 .000 -.7587 -.33032 -.6905* .10698 .000 -.9047 -.4763

* The Mean difference is significant at the .05 level.

among groups in terms of pre treatment and post treatment painthreshold changes.

Following pair wise comparison was done using Duncan’snew multiple range test. It showed statistically significantdifference (p<.05) between the pain threshold changes betweenGroup 3 as compared to Group 1 and Group 2.However, no

105Malik Manoj / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Graph 3: Percentage Increase in Mean Pain Threshold Values

Graph.1: Pre and post treatment pain threshold mean values

Graph.2: Mean difference in pain threshold values

106

significant difference was observed between mean painthreshold changes of group 1 and 2 (TABLE 4).

The result shows a statistically significant difference in painthreshold values of auricular TENS group as compared to controlgroup, thus the hypothesis that pain threshold with unilateraland bilateral auricular TENS will be significantly greater thanpain threshold of control group was supported, while nosignificant difference was seen between unilateral and bilateralauricular TENS group, thus the second hypothesis that bilateralauricular TENS treatment will significantly increase painthreshold in comparison of unilateral auricular TENS was notsupported.

Discussion

The study results indicate that auricular application ofacupuncture TENS significantly increased pain threshold. Thislead us to accept the research hypothesis that pain thresholdmeasured at wrist of subjects with unilateral and bilateralauricular TENS is significantly higher than the pain threshold ofcontrol group. The results of study lead to acceptance of nullhypothesis stating that both bilateral and unilateral TENS areequally effective in increasing pain threshold. This is inaccordance with previous studies, previous researchers havealso proved that experimental pain threshold after stimulationof auricular point would be significantly greater than changesnoted when placebo treatment was given10, 14,24,25

Previous researchers have also compared differencebetween auricular TENS, somatic TENS and a combination ofsomatic TENS and auricular TENS and found them equallyeffective in experimental pain threshold10. Results suggest thatunilateral auricular acupuncture TENS may be as effective asbilateral auricular TENS for increase in experimental painthreshold. Researchers have advocated bilateral TENSapplication if symptoms are bilateral or produced by a midlinelesion, while unilateral TENS is applied if patient’s pain isunilateral, though Chinese traditional treatment advocates bothside of body to be treated when administering acupuncture.

Regarding time of stimulation Noling et al applied auricularTENS on same four acupuncture points and found an increaseof 26% after 10 minutes25. In this study unilateral and bilateralTENS have found an increase of around 25% increase in meanpain threshold. The findings that all these values are in a narrowrange suggest that 45 seconds of auricular stimulation at eachpoint is sufficient to increase pain threshold. Further studies areneeded to assess whether less than 45 seconds of stimulationwould increase pain threshold.

Limitations

1. Small sample size2. Only young male and females were taken for study.

Clinical Implication

Findings of the study can be clinically correlated andauricular TENS can be used in pain relief in musculoskeletaland systemic disorders by stimulating corresponding auricularpoints with reference to auricular map. This can be especiallyuseful for the therapist in treatment of patients with chronic pain.The application of TENS can be done with equal benefit witheither unilateral or bilateral application.

Conclusion

In two groups of healthy adult subjects auricular,acupuncture like TENS, resulted in statistically significantincrease in pain threshold while control group demonstrated nosignificant increase in pain threshold. Statistically significantdifference existed between comparison between group

1(bilateral TENS ) and group 3(control group) and between grouptwo (unilateral TENS) and grup three (control group) regardingincrease in mean pain threshold while no significant differencewas observed between group one and group two. These resultsimply that auricular TENS is effective in increasing pain thresholdwhen compared with control group and both unilateral andbilateral auricular TENS are equally effective in increasing painthreshold.

References

1. Susan B, O’Sullivan “ Physical Rehabilitation: assessmentand treatment” , chronic pain, page 925, edition .

2. Paris DL, Baynes F, Gucker B: Effect of the neuroprobe inthe treatment of second degree ankle inversion sprains.Phy. Ther 63:35-40, 1983.

3. Leo KC, Use of electrical stimulation at acupuncture pointsfor the treatment of reflex sympathetic dystrophy in a child.A case report. Phys Ther 63:957-959, 1983.

4. Andersson, S.A, Pain control by sensory stimulation. InJ.J.Bonica, J.C.Liebeskind and D.G. Albe-Fessard ,Advances in pain research and therapy, Vol.3, Raven, NewYork, 1979, pp-569-585.

5. Andersson, S.A, Ericson, T., Holmgren, E. and Lindquist,G., Analgesic effects of peripheral conditioning stimulation.In J.J.Bonica and D.G.Albe-Fessard, Advances in painresearch and therapy, Vol. 1, Raven, New York, 1976,pp.761-768.

6. Andersson, S.A, Ericson, T., Holmgren, E. and Lindquist,G., Electro-acupuncture. Effect of pain threshold measuredwith electrical stimulation of teeth, Brain Research, 63(1973)393-396.

7. Eriksson, M.B.E and Sjolund. B.H, Acupuncture-likeelectroanalgesia in TNS resistant chronic pain. In YZotterman, Sensory functions of the skin, Pergamon Oxford,1976, pp. 575-581.

8. Eriksson, M.B.E and Sjolund. B.H and Nielzen, S, Longterm results of peripheral conditioning stimulation as ananalgesic measure in chronic pain, Pain, 6(1979) 335-347.

9. Hanson, P, and Ekblom , A., Transcutaneous electricalnerve stimulation (TENS) as compared to placebo TENSfor the relief of acute orofacial pain, Pain, 15 (1983), 157-165.

10. Donald H Lein, Jr Jo Ann Clelland, Cheryl J Knowles, JamesR Jackson” comparsion of effects of Transcutaneouselectrical nerve stimulation of Auricular, Somatic, and thecombination of auricular and somatic acupuncture pointson experimental pain threshold” physical therapy/ volume69, number 8/ august 1989, 49/671-56/678

11. Johnson, MI (1998) The analgesic effects and clinical useof acupuncture like TENS (AL-TENS). Physical TherapyReviews 3: 73-93.

12. Woolf, C. Thompson, J (1994) Segmantal afferent fibreinduced analgesia: TENS and vibration, in: Wall, P, Melzack,R. Text book of Pain, Churchill Livingstone, New York, pp1191-1208.

13. Willie Mao, Jawahar N. Ghia, Donald S. Scott, Gary H,Duncan and John M Gregg “high versus low intensityAcupuncture analgesia for treatment of chronic pain: effectson platelet serotonin, Pain, 8(1980) 331-342.

14. Oleveri AC, Clelland JA, Jackson J, et al: Effects of auriculartranscutaneous nerve stimulationon experimental painthreshold. Phys Ther66:12-16:1986.

15. Krause AW, Clelland JA, Knowles CJ, et al: Effects ofunilateral and bilateral auricular transcutneous electricalnerve stimulation on cutaneous pain threshold, Phy Ther67: 507-511, 1987.

16. T. I. Usichenko,1 Ch. Lehmann2 and E. Ernst3 Auricularacupuncture for postoperative pain control:a systematicreview of randomised clinical trials, Anaesthesia, 2008, 63,pages 1343–1348.

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17. Taras I. Usichenko, Sven Kuchling, Torsten Witstruck,Dragan Pavlovic, Maria Zach, Andre Hofer, Harry Merk,Christian Lehmann, and Michael Wendt Auricularacupuncture for pain relief after ambulatory knee surgery:a randomized trial, Auricular acupuncture” on page 1307b.

18. Kane,K,Taub,A(1975) A history of local electricalanalgesia. Pain 1; 125-138.

19. Melzack ,R, Wall, P (1965) Pain mechanism, a new theory,Science 150; 971-979.

20. Albere J.A.Koke, Jan S.A.G. Schouten et al, Pain reducingeffect of three types of trascutaneous electrical nervestimulation in patients with chronic pain: a randomizedcrossover trial, Pain, 16, 13-31, 1983.

21. John F Golding, Heather Ashton, Richard Marsh, WThompson, Transcutaneous electrical nerve stimulation

produces variables changes in somatosensory evokedpotentials, sensory perception and pain threshold; clinicalimplications for pain relief. Journal of neurology,Neurosurgery and Psychiatry, 1986; 49; 1397-1406.

22. Stephen Barrett, M.D, Auriculotherapy: A Skeptical Look,2008.

23. History of auricular medicine. Auricular MedicineInternational Web site, accessed Feb 1, 2008

24. Anthony G Longobardi, Jo Ann Cheryl J Knowles, JamesR Jackson, Effects of Auricular Transcutaneous Electricalnerve Stimulation On Distal Extremity Pain; a pilot study,Phy Thr, vol 69, number 1, January 1989.

25. Low and Reed, Electrotherapy Explained, (2002), TENS,p259-287.


108

Correlation of Body Mass Index to the Fasting Blood Sugar inYoung Adult PopulationMaliyannar Itagappa1, Vasudeva Murthy C R2

1,2Associate Professor, Department of Biochemistry, Department of Forensic medicine and Toxicology, S.S.Institute of MedicalSciences and Research Centre, Davangere-577005

Maliyannar Itagappa / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

An increase in body fat is generally associated with anincrease in risk of metabolic diseases such as type 2 diabetesmellitus; hypertension and dyslipidaemia.Body mass index (BMI)criteria are the primary focus as it is related to presence orabsence of obesity-related comorbid disease. Although severalstudies have shown a strong correlation between body massindex (BMI) and development of critical illness. The goal of ourstudy is to examine this relationship prospectively with fastingblood sugar in particular attention to the influence of concomitantdiabetes mellitus (DM).

Key Words

Body Mass Index, Fasting Blood Sugar and Diabetes.

Introduction

Body mass index, which relates weight to height, is themost widely used and simple measure of body size and isfrequently used to estimate the prevalence of obesity within apopulation 1. It is the most commonly used indicator of healthrisk associated with overweight (type-2 DM, insulin resistanceand cardiovascular disease) and underweight (osteoporosis,infertility) 2. A higher body mass index has been shown to accountfor up to 16% of the global burden of disease, expressed aspercentage of disability-adjusted life years3. Recent studies haveindicated that the life expectancy of adult with severe obesitymight be 15 to20% years lower than normal individuals 4. A bodyof information now available suggests the need for aconsideration not only of diabetes, but also of other disturbanceof glucose metabolism, such as impaired glucose tolerance, thathave emerged as independent risk factors for cardiovasculardisease mortality5. Diabetes mellitus is a common endocrinemetabolic disorder and a leading cause of death worldwide(Fraghilimani et al 2006). There are more than 154 milliondiabetics worldwide and its prevalence is on the increase in thedeveloping countries6. Diabetes is reaching epidemic proportionsglobally, particularly in south Asian region. A balanced diet andan active lifestyle can help all to maintain a healthy weight. Butfor kids with diabetes, these things are even more crucialbecause weight can influence diabetes, and diabetes caninfluence weight. Weight issues can affect kids and teens thathave type-1 or type-2 diabetes. Type-2 diabetes is characterizedby insulin resistance (IR) and relative insulin deficiency, henceearly identification is important for the management strategiesof DM.

The accumulation of visceral fat is particularly assumed toplay an important role in the etiology of Insulin Resistance notably

Address for correspondence:Maliyannar ItagappaAssociate Professor,Department of Biochemistry,S.S.Institute of Medical Sciences and Research Centre,Davangere-577005Email id: [email protected]

by the overexposure of the liver to free fatty acids, which resultsin insulin resistance and hyperinsulinemia. In this study an effortismade here to explore the correlation between the body massindexes with fasting blood sugar.

Objective

1. To study the correlate of fasting blood sugar with obesity,body mass index (BMI), body weight (BW).

2. To study the variation of Fasting Blood Sugar and BodyMass Index (BMI) in relation to male and female.


The present study was conducted at Department ofBiochemistry, S.S.Institute of medical sciences and researchcenter, Davangere.

Sample Size

257 students which included 130 were male students and127 were female students.

Procedure

Out of 300 students enrolled, 257 students were selected.The study was conducted at department of biochemistry,S.S.Institute of Medical sciences and research center,Davangere, India. After the Selection of the study group, theywere given with verbal and written information about the studyprior to providing written consent and invited for verbal andwritten feedback of individual results at the end of the study.Selected subject were screened based on Clinical historyincluding age, sex, drugs, smoking, alcohol consumption levelof physical exercise, previous history and family history ofdiabetes, dyslipidemia, coronary artery disease and peripheralvascular disease.

Inclusion Criteria

1. Study population with informed written consent with agegroup between 18 to 20 years (mean-19).

Exclusion Criteria Were

1. Age group outside the range of 18-20 years.2. Subjects with hypothyroidism, liver, kidney or heart failure,

neoplasm and the students receiving long term medicationsare excluded from the study.

Procedure

Height and weights of the selected subjects weredetermined by wearing light clothing without shoes. Eachparticipant’s weight and height were recorded and BMI wascalculated using height (m) and weight (kg). After 12 h ofovernight fasting, blood samples were collected under asepticconditions between 8 am - 8.30 am and deposited in dry tubes.The plasma was separated immediately using centrifugation at

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4,000 rpm for a period of 10 min. FBG was assessed byabsorbance method (diagnostica - Merck).

Normal Values of Fasting Blood Sugar (1)

F.B.S: 80-120 mg/dl

SISI Units BMI = Mass (kg) (Height (m))2

Imperial Units BMI = Mass (lb)*703(Height ( inch))2—————————

BMI = Mass (lb)*4.88(Height (ft))2

Body Mass Index

On the basis of BMI all students were divided into threegroups i.e., underweight whose BMI was less than 19 Kg/m2,normal whose BMI was between 19-26 Kg/m2 and overweightwhose BMI was more than 26 Kg/m2.

Table 3: Comparison of with different Body Mass Index with Fasting Blood Sugar In Male & Female Medical students

Males FemalesParameter Mean±SD Mean±SD Mean Difference tValue P* Value

BMI 22.66±3.36 21.36±3.49 1.32 3.07 P<0.05 SFBS 82.25±9.48 83.07±10.62 0.82 0.65 0.5 NS


For analysis of statistical significance both Oneway ANOVAtest and Tukey’s post hoc test were used.

Results and Discussion

Table 1: Correlating with Body Mass Index with Fasting BloodSugar in Males

Parameter Under Normal Over Weight Subject weightN=11 N=94 N=25

FBS 78.27±8.86 80.93±8.9 89.00±9.02

Table 4: Correlation Coefficient of BMI and FBS in both male and female medical students.

Males FemalesParameters Correlation Coefficient Sig Correlation Coefficient Sig

FBS 0.38 P<0.01S 0.52 P<0.01 S

Correlation coefficient of FBS is significant (P<0.01 S) in male and female

Table 2 Shows the higher levels of fasting blood sugar in theoverweight group than the normal female subjects.

BMI shows more significance in female and male and FBSshows not significant in both. The present study shows highervalves of FBS level in overweight group as well obesity but it isof normal range comparatively in normal and underweightsubjects.

Discussion

It the present study the normal limit of BMI was takenbetween 19-26 Kg/ m2 but many recent studies have shownthat Asian Indians have a significantly greater proportion of bodyfat than is found in Western populations. It is also clear that thehealthy levels of BMI and upper body adiposity are significantlylower for Asian Indians than for Westerners. Recently it has beencalculated that the normal cut-off value for BMI in Asian Indianadults is < 23 kg/m2. This has also been confirmed byrecommendations from the World Health Organization.Overweight excess energy intake, and physical inactivity havebeen associated with the rapidly rising number of diabetespatients7. Obesity is steadily becoming the greatest healthproblem in the developed world. The prevalence of overweightand obesity has reached pandemic proportions worldwide 8. Ithas recently been estimated 1.1 billion people are overfed andoverweight8. Overweight becomes obesity when extent that itmay adversely affect health and is most commonly defined bythe use of criteria involving the body mass index (BMI=kg/m2).BMI e” 25 can be associated with a reduced life expectancy anda risk of exacerbating many disease8.

Elevated fasting serum glucose level and a diagnosis ofdiabetes are independent risk factors for several major cancersand the risk tends to increase with an increased level of fastingserum glucose 9. Lowering blood sugar levels could reduce thecoronary heart diseases in both diabetes and non diabetics,according to researchers at the Johns Hopkins BloombergSchool of public health and other institution 10. The prevalenceof diabetes mellitus is highest among Indians (3.5%-16%),followed by Chinese and Malaysia 11.


Prevalence of obesity in western populations varies greatly,but a weighed estimate suggests prevalence between 15% and20% 12. Today more than 11 billion adults worldwide areoverweight, of which 312 millions are obese 3. There is a lot ofdata on the prevalence rates of obesity in the general populationin Bahrain and other Arabian Peninsula States 12 where theprevalence rate among adults is among the highest in the world.Prevalence of trend of overweight and obesity has beenincreasing among adults Arab, probably due to the effects ofmodernization, affluence, increased food consumption and theconcomitant changed to sedentary life styles 12.

A recent study conducted in Greece and in particular in theAttica region verified this major health issue and showed thatthe prevalence of adult overweight and obesity were 53% and20% in men and 31% and 15% in women respectively 13. In theUnited States , about one third of the population was overweightand another third was obese. The prevalence of adult overweight(BMI range 25-29, 9) and obesity is increasing regardless ofage socioeconomic or ethnicity differences14. As the prevalenceof obesity is increasing worldwide, data from epidemiologicalstudies in grebe demonstrate that a considerable proportion ofthe population is overweight or obese 13.

As 19.06% students of our total study populations areoverweight, so number of risk individuals is much higher.Therefore strategical design to limit diabetes mellitus andcardiovascular risk should address weight reduction duringchildhood and adolescence. However, the influence of obesityon cardiovascular risk begins before adulthood and overweightduring adolescence is associated with an increased risk ofcoronary heart diseases in male and female subjects 15.

In this study the prevalence of overweight and obesity is9.72% and 1.5% in male and that in female 9.3% and 1.16% of

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about 257 students, was higher than that reported in Europeancountries16 where the prevalence overweight and obesity were8% and 1% respectively, and among the medical students ofGreece University, the prevalence of obesity was 43%. It waslower than that reported in some Arab gulf countries 16. Forexample, among Kuwait college students overweight and obesitywere prevalent as 38.5% and 11% respectively 16. Obesity is amajor health problem in Kuwait, more than half of adult femalesand almost 1/3rd of adult males are obese 14.

Conclusion

Body mass index is one of the most accurate ways todetermine the health risks. Results of this study indicate thatthe strong relation between elevated fasting blood sugar withincreased BMI. The findings of this study calls for furtherinvestigation to determine the mechanisms that underlie thiscomplex relationship between obesity, diabetes, and other criticalillness.

Our study shows more underweight and overweight infemale than male and the fasting blood sugar were found morein female than male. From Present study we can say that femalesare more prone to develop diabetes mellitus than males. Thusthis study focus on Obesity as a risk factor for impaired FBS inadult population hence requires implementation of local andnational level programs to prevent overweight and obesity.

Acknowledgements

Authors are thankful to the Principal, Prof and head of thedepartment of Biochemistry, students and technicians of theCentral Lab of S S I Medical Science & Research Center forproviding necessary facilities to perform this research work.

Refernces

1. Ali Chehrei, Saeidsadrnia, Ammar Hassanzadeh K,Mohammad,Ali Daneshmand, Salal Rezaei, Correlation ofdyslipidemia with waist to height ratio, Waist circumferenceand body mass index in Iranian, Asia Pac J Clin Nutr 2007:16(2):248-253.

2. Guylaine CR, Helga Saudny-Unterberger , Harriet V,Kuhnlein, Grace M, Egeland; Body mass index mayoverestimate the prevalence of overweight and obesityamong the INUIT; International J of Circ umpolar health;2005:64(2); 163-169

3. Farhad Hosseinpanah, Mehdi Rambod and FereidounAzizi; Population attributable risk for diabetes associatedwith excess weight in Tehranian adults: a population basecohort study: BMC Public health 2007:7:328.

4. Horri M, Vakili R, Evalution of cardiovascular and lipid profileabnormalities in obese children and adolescents, Iran JMed Sci 2006: 31(2):87.-90

5. Ferdinando CS, Ornella C, Rodolfo N, Biagio C, RaffaeleM, Michele T, Giannantonio N, Roberto T, Domenico C;Glucose metabolism and coronary heart diseases inpatients with normal glucose tolerance; JAMA2004:291:15:1857-1863.

6. Ugwu CE, Ezeanyika LUS, Daikwo MA and Amana R; Lipidprofile of a population of diabetic patients attending NigerianNational Petroleum Corporation Clinic, Abuja,2009; AFR Jof Biochem Research, 3(3),66-69.

7. Gertraud M, Andrew G, Grace M, Sangita S,Marjorie M,Brian E H, Laurence N K,; Diabetes prevalence and bodymass index differ by ethnicity; The multiethniccohort.Ethnicity and disease, 2009, vol 19.

8. Huseyin Ozdemir, Hakan Artas. Selami Serhatlioglu, ErkinOgur ;Effects of overweight on luminal diameter, flowvelocity and intima-media thickness of carotid arteries.Diagn interv Radiol ;2006 12;142-146

9. Jee SH, Ohrr H, Sull JW, Yun JE, Ji M, Samet JM; Fastingserum glucose level and cancer risk in Korean men andwomen; JAMA 2005:12:293(2):236-6.

10. Soo-Kyung Lee, Relationships between body mass index,diabetes and blood glucose level in south Korean adults;2005 Korean national health and nutrition survey; Republicof Korea.

11. Haziz AS, Zaitun Y, Kandiah M and Chan SP; Glycemiccontrol, lipid profile, blood pressure and body weight statusamong diabetics in rural Malaysia; International medicaljournal 2009:8(2):21-27.

12. Faisal Al-Mahroos, Khaldoon Al Roomi: Obesity amongadult Bahraini poppulstion; Impact of physical activity andeducational level; Annals of Saudi Medicine 2001:21:3-4:183-192.

13. Paul Farajian, Efthimia Renti and Yannis Manios. Obesityindices in relation to cardiovascular diseases risk factorsamong young adult female students, British journal ofnutrition 2008:99,918-924.

14. Fasial H, Al Orifan, Hanan E, Badr, Mohammad AbdulSubour Se’adah, Khalid EK, Basel AL Kordi, Adel Abass;Obesity and cardiovascular risk factors in Kuwaiti Adulats ,Kuwait medical J 2007:39(2):162-166.

15. Jawed Aziz, Nadeem A Siddiqui, Imran A siddiqui, AmirOmair: Relation of body mass index with lipid profile andblood pressure in young health students AT ZiauddinMedical University; J Ayub Med Coll Abdottabad2003:15(14).

16. Jasim N AI-Asadi, Omvan S Habib, Lami Al-Naama:Cardiovascular risk factors among college students:Bahrrrain Med Bull 2006: 28(3); 1-8.


111

To Compare the Effects of High and Low FrequencyTranscutaneous Electrical Nerve Stimulation on AcupuncturePoints in Experimental Pain ThresholdManish Jain1, Nidhi Sharma2, Sumit Kalra2

1BPT Student, 2Lecturer, Banarsidas Chandiwala Institute of Physiotherapy, New Delhi

Manish Jain / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

This study compared the effects of high and low frequencytranscutaneous electrical nerve stimulation on acupuncturepoints in experimental pain threshold at the wrist. 70 healthysubjects, aged 18-24 years, were distributed into 2 groups: 1)High Frequency TENS, 2) Low Frequency TENS. Pain thresholdwas measured immediately before and after the treatment. Painthreshold significantly increased in both the groups followingtreatment, with statistically significant differences in mean painthreshold changes between the two groups also. The resultssuggest that low frequency TENS is more effective than highfrequency TENS for increasing experimental pain threshold.

Key Words

High frequency, low frequency, transcutaneous electricalnerve stimulation, acupuncture points, pain threshold.

Introduction

Transcutaneous electrical nerve stimulation, morecommonly referred to as TENS is defined as transcutaneouslyapplied electrical stimulation of the skin to relieve pain byinterfering with the neural transmission of signals from underlyingpain receptors 1, 2.

TENS units produce a continuous train of pulsed current atfrequencies in the range 1 to 120 Hz, some as high as 200 Hz2.

Generally TENS is applied at high frequency (>50 Hz) withan intensity below motor contraction (sensory intensity) or lowfrequency (<10 Hz) with an intensity that produces motorcontraction3.

In clinical practice, TENS is predominantly used for itssymptomatic relief of pain through the pain gate mechanism.The “gate control theory of pain”4 proposed that painperception is not simply a direct result of activating pain fibers,but modulated by interplay between excitation and inhibition ofthe pain pathways.

The purpose of this study is to compare the effects of highand low frequency TENS on acupuncture points in experimentalpain threshold.

Acupuncture is the procedure of inserting andmanipulating filiform needles into various points on the body torelieve pain or for therapeutic purposes5. The acupuncturetechnique that has been most often studied scientifically involvespenetrating the skin with thin, solid, metallic needles that aremanipulated by the hands or by electrical stimulation6.

The four acupuncture points used in this study are7:-1. LI 5 Acupuncture Point - Yang Xi2. LI 4 Acupuncture Point - He Gu3. TH 4 Acupuncture Point - Yang Chi4. TH 5 Acupuncture Point - Wai Guan

Acupuncture like TENS (AL-TENS) is defined as theinduction of forceful but non-phasic muscle contractions atmyotomes related to the origin of the pain8,9,10,11,12,13. However,there is inconsistency in the use of the term ‘AL-TENS’, as somecommentators describe AL-TENS as the delivery of TENS overacupuncture points irrespective of muscle activity14,15,16,17.

The purpose of AL-TENS is to selectively activate small

diameter fibres (Aä or group III) arising from muscles(ergoreceptors) by the induction of phasic muscle twitches.Evidence suggests that AL-TENS produces extra segmentalanalgesia in a manner similar to that suggested for acupuncture8.

TENS induced activity in small diameter afferents has alsobeen shown to produce extra segmental analgesia through theactivation of structures which form the descending pain inhibitorypathways, such as periaqueductal grey (PAG), nucleus raphemagnus and nucleus raphe gigantocellularis18, 19, 20.

A study was conducted by James R Jackson, Cheryl JKnowles, Jo Ann Clelland and Donald H Lein, Jr compared theeffects of high intensity, low frequency transcutaneous electricalnerve stimulation of auricular, somatic, and combined auricularand somatic acupuncture points on experimental pain thresholdmeasured at the wrist. The results indicate that TENS appliedto any of the three sets of acupuncture points equally increasespain threshold, thus possibly increasing options in choosingstimulation sites for treating patients with pain21.

A study was conducted by Berlin FS, Bartlett R, Black JDto determine acupuncture and placebo effects on delaying theterminating response to a painful stimulus. Response latencieswere recorded before and after needling, which includedelectrical stimulation. Needles placed in specific acupuncturepoints delayed onset of the pain-terminating response slightlymore than needles inserted as placebos. Even with needles inappropriate acupuncture points, analgesia was slight andsubjects still experienced pain24.

A study conducted by Chapman CR, Benedetti C, ColpittsYH, Gerlach R. to demonstrate that naloxone fails to reversepain threshold elevated by acupuncture. Because endorphinscan be released in response to a stressor, endorphin presencesometimes correlates with acupunctural treatment in animalstudies and some human studies, especially those involving painpatients. The primary analgesia elicited by acupuncturalstimulation seems to involve other mechanisms25.

A study was conducted by Kiser RS, Khatami MJ, GatchelRJ, Huang XY, Bhatia K, Altshuler KZ to determine thatacupuncture relief of chronic pain syndrome correlates withincreased plasma met-encephalin concentrations. Plasma beta-endorphin concentrations were unchanged. The degree ofsymptom relief was correlated with the increase in plasma met-enkephalin26.

Method

Source & Selection Criteria

70 healthy individuals of age 18-24 years from BanarsidasChandiwala Institute of Physiotherapy.

Inclusion Criteria

• Asymptomatic Healthy Individuals• Age Group 18-24 Years• Both Males And Females

Exclusion Criteria

112

• Any subjects who used cardiac pacemakers / metal implants• Any neurological disorders / mental retardation cases• Subjects who took opiate pain medications or central

nervous system depressants or stimulants

Instrumentation

• Electrical Stimulator (International Electro Medical made)• Trans cutaneous electrical nerve stimulator (International

Electro Medical made)• Acupuncture points chart• Stool• Watch

Procedure

• Subjects were divided into two groups,i.e, Group 1 andGroup 2 of 35 subjects each.

• Group 1 received high frequency TENS on acupuncturepoints of the wrist while Group 2 received low frequencyTENS on acupuncture points of the wrist.

• The 4 acupuncture points used were :-1. Wiaguan (TH 5)2. Yangchi (TH 4)3. Yangxi (LI 5)4. Hegu (LI 4)• All subjects sat comfortably on the stool with their arm

supported on a pillow and experimental pain threshold wasmeasured immediately before and after the treatment.

Pain Threshold Measurement

• Before the experiment began, the subjects were allowedto feel the electrical current at their right wrists to familiarizethemselves with the sensation.

• We instructed the subjects to recognize and verbally reportthe instant they perceived any electrical sensation at theright wrist and then again when they experienced a mildlypainful pinprick sensation.

• To determine each subject’s experimental pain threshold,electrical stimulation was applied to the skin over the distalend of the left radius.

• The dispersive electrode was applied behind the subject’sneck, between the levels of the seventh cervical vertebraeand upper thoracic vertebrae.

• The point over the distal radius was marked with ink toensure all measurements were taken at the same point.

• Acupuncture point LI 5, located near the distal end of theradius was avoided.

• The intensity was increases systematically by 0.1 mAincrements at one second intervals until the subject reporteda distinct painful pinprick sensation.

• This sensation was recorded as the subject’s experimentalpain threshold.

• We obtained and averaged three pain thresholdmeasurements in each session to determine each subject’smean experimental pain threshold.

Treatment

• The subjects removed all jewelry before treatment. Thedispersive electrode was tied to the left hand of eachsubject.

• Acupuncture point charts are used to locate the appropriateacupuncture points for each subject.

• High and low frequency TENS was used to stimulate theacupuncture points for the two groups.

• The high frequency TENS current used to stimulate theacupuncture points was a positive polarity current delivered

at 100 Hz with a pulse width of 150 µs.• The low frequency TENS current was a positive polarity

direct current delivered at 5 Hz with a pulse width of 150µs.

• Subjects responded verbally when the first began to feelthe stimulus and then again when the intensity reachedeach subject’s tolerance.

• Each point was stimulated for 60 seconds at this intensity.Stimulus intensity was lowered slightly during treatment ifrequired by the subject.

• Stimulus intensity was lowered slightly during treatment ifrequested by the subject.

• Experimental pain threshold levels were measured againimmediately after the treatment.

Data Analysis

Mean pain threshold values for all the groups are shown inTable 1. Descriptive statistics for pain threshold were calculatedfor the pre treatment and post treatment measurements and forthe change between measurements. A t-test and z-test was usedto test the data for statistical significance. The t-test can be usedto determine the differences between the pre treatment and posttreatment means within each case. The z-test is used todetermine the differences between the mean of changes in thepre treatment and post treatment measurements between twogroups.

Pre treatment and post treatment comparisons in anindividual case were made with the help of paired t-test.

Manish Jain / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

GROUP MEAN STANDARD MEDIANDEVIATION

LOWFREQUENCY

Pre treatment 10.61 3.07 10.2Post treatment 13.25 4.06 12.7Change 2.8 1.93 2.5

HIGHFREQUENCYPre treatment 9.85 2.71 9.4Post treatment 11.96 3.70 11.2Change 2.15 1.72 2.4

Table 1: Mean Pain Threshold Measurements (mA)

Graph 1: Experimental pain threshold

113Manish Jain / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Comparison of changes in the pre treatment and post treatmentmeasurements between two groups were made with the help ofz-test. 5 percent level of correction was used for all the tests.The mean pre treatment and post treatment pain thresholdsare shown in Graph 1.

Results

The paired t-test showed a statistically significant effect,therefore there was statistically significant difference in individualgroups in terms of pre treatment and post treatmentmeasurement in both the cases. The z-test also showed thatthe mean change for the groups differed statistically from eachother in both the cases.

The changes recorded in the pain threshold levels are:1. An increase of 26.39% in the pain threshold levels in low

frequency TENS.2. An increase of 21.82% in the pain threshold levels in high

frequency TENS.This study supported our expectations that significant

changes would occur in the experimental pain threshold,measured at the wrist, after stimulation of the acupuncture pointsin the two cases we divided according to our aims.

The hypothesis that low frequency TENS is more effectivethan high frequency TENS in elevating experimental painthreshold levels was supported. Significant differences werefound among the groups mean change values from pre treatmentto post treatment measurements.

Discussion

Other studies have shown that stimulation of acupuncturepoints resulted in statistically significant increases in experimentalpain threshold. We also found out that statistically significantpain threshold elevation occurred following stimulation ofacupuncture points by either low frequency TENS (t-value 3.0684with 99.69% confidence level) and high frequency TENS (t-value2.7218 with 99.18% confidence level).

The results of our study suggest that stimulation ofacupuncture points by low frequency TENS is more effectivethan high frequency TENS in increasing pain threshold levels(z-value 2.142 with 96.8% confidence level). In our studystimulation of acupuncture points by low frequency TENSresulted in greatest pain threshold change. This change, wasstatistically different from the pain threshold changes in the othergroup that received high frequency TENS. Clinically, this findingimplies that a physical therapist may prefer low frequency TENSover high frequency TENS to stimulate the acupuncture pointsof an individual patient as it is expected to give better results.The analgesic effects will be better after stimulation of theacupuncture points by low frequency TENS.

Studies done by researchers done in the earlier years haveshown that a delay exists before maximum analgesia occurs inexperimental pain threshold following acupuncture pointstimulation. Nailing et al reported that the change in mean painthreshold increased from 11.7% immediately followingacupuncture point stimulation to 25.6% 10 minutes aftertreatment22. Kitade and Hyodo measured experimental painthreshold both during and after either acupuncture pointstimulation23. They also reported that maximum analgesia wasnot achieved immediately post treatment23. Kitade and Hyodoobserved that experimental pain threshold reached its maximumat 30 or 50 minutes into acupuncture point stimulation21. In theseentire studies maximum pain threshold levels were not achievedimmediately, regardless of whether pain threshold was measuredfollowing or during either auricular or somatic acupuncture pointstimulation23. This delay before maximum analgesia could bethe time required for the maximal release and function ofendorphins. All of these studies also showed that pain thresholdremained elevated after cessation of acupuncture point

stimulation23. Our study showed that stimulation of acupuncturepoints resulted in immediate increase in experimental painthreshold; further post treatment measurements were not taken.Future studies should determine whether it will continue toincrease or remain significantly elevated over time followingacupuncture point stimulation.

Duration of treatment also has been shown to be a factorin effective acupuncture point stimulation. In our study theapplication of low frequency and high frequency TENS for 60seconds resulted in 27.63% and 23.85% increase respectivelyin experimental pain threshold. Studies should also be performedto determine the duration of treatment required to achieve optimalincreases in pain threshold with high and low frequency TENS.

Comparisons between experimental pain and clinical painwere not made in this study because they may differ in theirresponse to the mode of TENS used in acupuncture pointstimulation. Clinical studies may show that, of the mode of TENSinvestigated in this study, one set may be more effective inalleviating pain. Nonetheless, experimental pain suppressionstudies, such as this study may be an important first step inevaluating and understanding potentially effective means of painalleviation in the clinic9.

Conclusion

In a group of 70 healthy subjects, low and high frequencyTENS administered to a set of acupuncture points resulted instatistically significant increase in experimental pain threshold.Also, statistically significant differences existed in the elevatedpain threshold change values among the groups receiving lowand high frequency TENS. These results suggest that lowfrequency TENS is more effective than high frequency TENSfor increasing experimental pain threshold. Because theseresults imply that stimulation of the acupuncture points by lowfrequency TENS is more effective than high frequency TENS,this finding implies that a physical therapist may prefer lowfrequency TENS over high frequency TENS to stimulate theacupuncture points of an individual patient as it is expected togive better results. Further research to compare low and highfrequency TENS with patients with specific pain condition isneeded.

References

1. Merriam-Webster’s Medical Dictionary2. Low J, Reed A ,19943. Robinson and Sydney-Mackler,20084. Melzack, R, Wall, P (1965) Pain Mechanisms: A new theory.

Science 150: 971-9795. Dorland’s Pocket Medical Dictionary, 25th ed. W. B.

Saunders Co., 19956. Traditional Chinese Medicine(TCM); National Center for

Complementary and Alternative Medicine7. Ferro, Barbara, New England School Of Acupuncture8. Eriksson, M, Sjolund, B (1976) Acupuncture like electro

analgesia in TNS resistant chronic pain. In: Zotterman, Y(ed). Sensory functions of the skin. Oxford/ New York;Pergamon Press, pp 575-581

9. Johnson, MI (1998) The analgesic effects and clinical useof acupuncture-like TENS (AL-TENS). Physical TherapyReviews 3: 73-93

10. Meyerson, B (1983) Electrostimulation procedures: effectspresumed rationale, and possible mechanisms. In: Bonica,J, Lindblom, U, Iggo, A (eds.) Advances in Pain Researchand Therapy, vol 5. Raven, New York, pp 495-534

11. Sjolund, B, Eriksson, M, Loeser, J (1990) Transcutaneousand implanted electric stimulation of peripheral nerves. In:Bonica JJ (ed) The Management of Pain, Vol II, Lea andFebiger, Philadelphia, pp 1852-1861

12. Walsh, D (ed) (1997c) TENS. Clinical Applications and

114 Manish Jain / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Related Theory. Churchill Livingstone, New York;13. Woolf, C, Thompson, J (1994) Segmental afferent fibre-

induced analgesia: transcutaneous electrical nervestimulation (TENS) and vibration. In: Wall, P, Melzack, R(eds) Textbook of Pain, Churchill Livingstone, New York,pp 1191-1208

14. Lewers, D (1989) Transcutaneous electrical nervestimulation in the relief of primary dysmenorrheal. PhysicalTherapy 69: 3-9

15. Lewis, SM (1990) Effects of auricular acupuncture liketranscutaneous electrical nerve stimulation on pain levelsfollowing wound care in patients with burns: a pilot study.Journal of Burn Care and Rehabilitation 11: 322-329

16. Longobardi, (1989) Effects of auricular transcutaneouselectrical nerve stimulation on distal extremity pain: a pilotstudy. Physical Therapy 69: 10-17

17. Rieb, L, Pomeranz, B (1992) Alterations in electrical painthresholds by use of acupuncture like transcutaneouselectrical nerve stimulation in pain free subjects. PhysicalTherapy 72: 658-667

18. Chung (1984a) Prolonged inhibition of primatespinothalamic tract cells by peripheral nerve stimulation.Pain 19: 259-275

19. Chung (1984b) Factors influencing peripheral nervestimulation produced inhibition of spinothalamic tract cells.Pain 19: 277-293

20. Wolf, CJ, Mitchell, D, Barrett, GD (1980) Antinociceptiveeffect of peripheral segmental electrical stimulation in therat. Pain 8: 237-252

21. Lein DH Jr, Clelland JA, Knowles CJ, et al: Comparison ofthe effects transcutaneous electrical nerve stimulation ofauricular, somatic, and the combination of auricular and

somatic acupuncture points on experimental pain threshold.Physical Therapy Journal 69: 671-678,1989

22. Noling LB, Clelland JA, Jackson JR, et al: Effect oftranscutaneous electrical nerve stimulation at auricularpoints on experimental cutaneous pain threshold. PhysicalTherapy 68:328-332,1988

23. Lundeberg T (1993). “Peripheral effects of sensory nervestimulation (acupuncture) in inflammation andischemia”.Scandinavian journal of rehabilitation medicine.Supplement 29: 61–86

24. Berlin FS, Bartlett RL, Black JD: Acupuncture and placebo:Effects on delaying the terminating response to a painfulstimulus. Anesthesiology 42:527-531, 1975

25. Chapman CR, Benedetti C, Colpitts YH, et al: Naloxonefails to reverse pain thresholds elevated by acupuncture:Acupuncture analgesia reconsidered. Pain 16:13-31, 1983

26. Melzack R, Stillwell DM, Fox EJ (1977). “Trigger points andacupuncture points for pain: correlations andimplications”. Pain 3 (1): 3–23

27. Kiser RS, Gatchel RJ, Bhatia K, et al: Acupuncture relief ofchronic pain syndrome correlates with increased plasmamet- encephalin concentrations. Lancet 2:1394-1396, 1983

Undertaking

I undertake that all the below mentioned people are co-authors of my study.

1. Dr. Nidhi Sharma (Lecturer- Banarsidas ChandiwalaInstitute of Physiotherapy)

2. Dr. Sumit Kalra (Lecturer- Banarsidas Chandiwala Instituteof Physiotherapy)

115Frank van Eijkeren / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Address for correspondence:Mirrian HilbinkJeroen Bosch HospitalJeroen Bosch AcademyP.O. Box 901535200 ME ‘s-HertogenboschThe NetherlandsTelephone: +31 (0)73-5532970E-mail: [email protected]

Assessment of motor function in Multiple Sclerosis patientstreated with MethylprednisoloneFrank van Eijkeren1, Ruud Reijmers1, Erik van Munster2, Mirrian Hilbink3

1Physiotherapist, Department of Physiotherapy, 2Neurologist, Department of Neurology, 3Clinical Epidemiologist Jeroen BoschAcademy, Jeroen Bosch Hospital, ‘s-Hertogenbosch, The Netherlands

Abstract

The objective of the current study was to exhaustivelyassess whether Methylprednisolone produces changes inphysical functioning in different populations of people with MS,by using a battery of established instruments. Therefore, variousmeasurement instruments regarding functioning of themovement system as well as movement activities were appliedto a group of Multiple Sclerosis patients treated withMethylprednisolone. Participating patients completed the batteryof selected instruments before the start of treatment withMethylprednisolone and they were then followed up 12 weeksafter treatment initiation. Scores on the various instrumentsincluded in the physiotherapeutic measurement protocol enablesa valid assessment of the course of motor functioning of MultipleSclerosis patients. Motor functioning of patients in the relapsing-remitting phase of Multiple Sclerosis showed significantimprovement in nearly all components after treatment withMethylprednisolone, whereas motor functioning of patients inthe secondary-progressive phase of the disease remainedunchanged.

Methylprednisolone seems to improve the motor functionof Multiple Sclerosis patients in the relapsing-remitting phase.As outcomes of the measurements included in thephysiotherapeutic measurement protocol can serve as aguideline in decision making about treatment, thephysiotherapeutic measurement protocol has added value inthe treatment of patients suffering from Multiple Sclerosis.

Key Words

Multiple Sclerosis; measurement protocol; motorfunctioning; physiotherapy; Methylprednisolone.

Introduction

Multiple Sclerosis (MS) is a chronic disease of the centralnervous system.1 Based on the course of the disease, differenttypes of MS can be distinghuished.2 Relapsing-remitting (RR)MS is the phase in which exacerbations occur, which leave fewor no remaining symptoms. Secondary progressive (SP) MS isthe phase in which exacerbation can still occur, but in which thedisease symptoms gradually increase. This phase often followsthe RR phase. Furthermore, primary progressive (PP) MS ischaracterised by a gradual deterioration without exacerbations,whereas acute MS occurs suddenly and runs a very progressivecourse.

MS has a strong influence on patients’ motor functioning.A number of previous studies investigated the course of motor

functioning in MS patients. Unlike the situation for Parkinson’sdisease, a test battery composed of established instruments formonitoring functions of the movement system and movementactivities of MS patients is unavailable as yet. Therefore, thelarge majority of prior studies assessed the course of motorfunctioning in this patient group by using a single instrument. Alarge part of these studies concerned MS patients treated withMethylprednisolone, as this is a commonly used treatment optionin MS patients. Methylprednisolone is prescribed for both anexacerbation of the disease and maintenance treatment in thechronic phase of the disease.3,4,5,6 The Expanded Disability StatusScale (EDSS), the Visual Analogue Scale (VAS) and theNeurological Rating Scale (NRS) were used in previous studiesin order to assess motor functioning in Methylprednisolone-treated MS patients with an exacerbation of their disease.7,8,9,10

The aim of treatment in this phase of the disease is to speed uprecovery from the exacerbation and to achieve recovery with asfew remaining symptoms as possible. Goodkin used the ninehole peg test to investigate the motor function in patients duringthe SP phase of MS, where the aim of treatment is to slow downdeterioration of the functioning.11,12

To our knowledge, prior studies did not make use of a testbattery composed of established instruments pertaining to abroad range of functions of the movement system and movementactivities of patients suffering from MS. As motor functioning isan essential part of the evaluation of the course of the diseaseduring outpatients’ clinic follow-up visits, the availability of athorough insight in this domain of functioning is desirable.13,14

The aim of the current study was to exhaustively assess whetherMethylprednisolone produces changes in physical functioningin different populations of people with MS, by using a battery ofestablished instruments.

Material and Methods

Measurement instruments

The following measurement instruments, having provenvalue in the examination of motor functioning of neurologicalpatients, and where possible particularly of MS patients, wereused.• Hand grip strength meter (GRIP) for the measurement of

muscle strength in the hands. Mathiowetz15,16 showed thatgrip strength can be measured in a reliable and validmanner with an inter-evaluator reliability of 0.99.

• Handheld dynamometry (EXTKN and FLEXEL) for themeasurement of muscle strength of the extensors of theknees and the flexors of the elbows. Bohannon17 andAndrews18 demonstrated that muscle strength can bereliably measured with a handheld dynamometer if astandardised measurement is performed; the inter-evaluator reliability is 0.94 for the flexors of the elbow and0.90 for the extensors of the knee.

• 10-metre walking test, maximum walking speed (10MWALK) for walking ability. Wade19, Collen20 and Holden21

demonstrated that walking speed can be measured simply,reliably and validly for the neurological patient in generaland also for the MS patient more specifically. The test-retestreliability is 0.97 and the construct validity compared to thefunctional ambulation categories is 0.80.

116 Frank van Eijkeren / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Manual dexterity Manual dexterity

49 (68) 31 (24) P = 0.01* 24 (5) 22 (5) P = 0.13

49 (68) 31 (24) P = 0.13 24 (5) 22 (5) P = 0 01*

• Nine hole peg test (NHPT) for manual dexterity.Mathiowetz(22) demonstrated good reliability of thisinstrument. The inter-evaluator reliability is 0.97 for the righthand and 0.99 for the left hand. The construct validitycompared to the Purdue Pegboard is 0.61 for the right handand 0.53 for the left hand.

• The berg balance scale(23,24) (BBS) for functional balancemeasures 14 everyday balance moments. Taking intoaccount the clinimetric properties: the inter-evaluator andintra-evaluator reliability are 0.98 and 0.99, respectively andthe construct validity compared to the Timed Up and GoTest and Tinetti Balance Test is 0.76 and 0.91, respectively.The instrument provides an ordinal result, with a range of 0– 56; 0 = very poor and 56 = optimal.

• Functional ambulation categories (FAC) for the degree ofassistance or supervision whilst walking. Holden(25)demonstrated that this instrument can be used in a reliableand valid manner for MS patients. The inter-evaluator andintra-evaluator reliability are 0.79 and 0.96 respectively, andthe construct validity compared to the 10-metre walkingtest is 0.80. The instrument provides an ordinal result, witha range of 0 – 5; 0 = very poor and 5 = optimal.

Patients

The study population consisted of patients who wereadmitted to the day dare centre for treatment. They were treatedwith Methylprednisolone, via intravenous administration (daily1000 mg during three consecutive days).

Inclusion criteria were a diagnosis of MS (RR or SP phase)and aged 16 years of older.

Exclusion criteria were being unable to complete the motortasks properly due to cognitive problems; being unable to walkand having another pathology or use of medication that affectsthe course of MS. Written informed consent was obtained fromall participants.

Measurements

The measurements were performed by an experiencedphysiotherapist. The first measurement took place before thestart of treatment with Methylprednisolone (T0). AsMethylprednisolone remains active for approximately 3 months,a follow-up measurement was performed 12 weeks after thestart of Methylprednisolone treatment (T1). The order of themeasurement instruments was remained the same in all cases.All measurements were performed by the same physiotherapist.

Statistical Analyses

Statistical calculations were performed using SPSS forWindows (version 16.0).

A P-value of less than 0.05 was considered to indicatestatistical significance. Firstly, descriptive statistics wereperformed. After that, all continuous variables were judged forfit to the normal distribution by using stem-and-leaf plots andquantile-quantile (QQ) plots.

In case of abnormal distribution, the Signed Rank Test(Wilcoxon for paired observations) was used for testing. In caseof normal distribution, the Student’s t test for paired observationswas used for testing. All tests were two-sided.

Findings

Patients in the RR phase of MS

Eighteen patients were in the RR phase of MS. One ofthem dropped out because he became severely ill during thecourse of the study and required hospitalisation. The large

majority of patients in this phase of MS were female (88,2%).The mean age of this patient group was 37,3 years and theywere suffering from MS on average for 2.8 years.

Both baseline and follow-up scores of this group arepresented in Table 1. The functional balance (BBS) improved inthis group from 51 to 55 (P=0.008). The muscle strength of theextensors of the knees showed for both the right and left leg asignificant improvement, from 233 to 267 N on the right (EXTKNright; P=0.03) and from 223 to 259 N on the left (EXTKN left;P=0.03). The degree of assistance for walking (FAC) did notchange significantly (P=0.46). The muscle strength of the flexorsof the elbows increased for both right and left, from 180 to 191 Nfor the right (FLEXOR right; P=0.39) and from 160 to 176 N forthe left (FLEXOR left; P=0.50). The grip strength in the handsimproved for both right and left hand significantly, from 212 to254 N for the right (GRIP right; P=0.049) and from 190 to 244 Nfor the left (GRIP left; P=0.03). The manual dexterity for theright arm (NHPT right) significantly changed (P=0.01), whereasthe manual dexterity for the left arm (NHPT left) changed onlyslightly (P=0.13). The walking speed (10M WALK) improved from9 to 7 seconds (P=0.001).

Patients in the SP phase of MS

Eleven patients were in the SP phase of MS. Two patientsdropped out due to progression of the disease during the courseof the study. They were no longer able to stand and walkindependently or come to the hospital. The large majority ofpatients in this phase of MS were male (77,8%). The mean ageof this patient group was 46,7 years and they were sufferingfrom MS on average for 11.3 years.

Both baseline and follow-up scores of patients in the SPphase are presented in Table 2.

The functional balance (BBS) in this group changed slightlyfrom 36 to 38 (P=0.55). The muscle strength of the extensors ofthe knees increased for both the right and left leg for this group,from 239 to 249 N on the right (EXTKN right; P=0.62) and fromto 254 to 262 N on the left (EXTKN left; P=0.62). The degree ofassistance required for walking (FAC) remained unchanged(P=1.00). The muscle strength of the flexors of the elbowsincreased for both right and left, from 203 to 216 N for the right(FLEXOR right; P=0.53) and from 206 to 215 N for the left(FLEXOR left; P=0.23). The grip strength of the right handchanged from 274 to 272 N (GRIP right; P=074) and for the lefthand from 277 to 303 N (GRIP left; P=0.03). The manualdexterity for the left arm (NHPT left) changed from 41 to 37seconds (P=0.19), whilst right (NHPT right) remained unchanged(P=1.00). The walking speed (10M WALK) improved from 19 to18 seconds (P=0.90).

Conclusion

The Patient Population in the RR phase of MS

The functional balance, the muscle strength of the extensorsof both knees, the grip strength of the hands and the walkingspeed all improved significantly. The responsiveness of the FACseems to be too small for this group. Furthermore, the manualdexterity for the right arm showed significant improvement,whereas the left did not. Of the 17 patients, 15 were right-handed

117Frank van Eijkeren / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Table 1: Mean scores (standard deviation) of Methylprednisolone-treated patients in the RR phase at T0 and T1 (n=17)

* P < 0,05

T0 T1 P-value

Functional Balance 51 (5) 55 (3) P = 0.008*

Muscle strength 233 (65) 267 (48) P = 0.03*right knee

Muscle strength 223 (77) 259 (50) P = 0.03*right knee

Assistance for 4.4 (0.5) 4.5 (0.5) P = 0.46Walking

Muscle strength 180 (42) 191 (54) P = 0.39right elbow

Muscle strength 160 (39) 176 (59) P = 0.50left elbow

Grip strength 212 (76) 254 (97) P = 0.049*right hand

Grip strength 190 (82) 244 (100) P = 0.03*left hand

Manual dexterity 24 (5) 22 (5) P = 0.13right arm

Manual dexterity 49 (68) 31 (24) P = 0.01*left arm

Walking speed 9 (5) 7 (2) P = 0.001*

Table 2: Mean scores (standard deviation) of Methylprednisolone-treated patients in the SP phase at T0 and T1 (n=9)

T0 T1 P-value

Functional Balance 36 (12) 38 (15) P = 0.55

Muscle strength 239 (53) 249 (46) P = 0.62right knee

Muscle strength 254 (52) 262 (53) P = 0.62right knee

Assistance for 4 (0) 4 (0) P = 1.00Walking

Muscle strength 203 (64) 216 (65) P = 0.53right elbow

Muscle strength 206 (51) 215 (38) P = 0.23left elbow

Grip strength 274 (43) 272 (31) P = 0.74right hand

Grip strength 277 (34) 303 (38) P = 0.03*left hand

Manual dexterity 43 (19) 43 (23) P = 1.00right arm

Manual dexterity 41 (17) 37 (12) P = 0.19left arm

Walking speed 19 (14) 18 (14) P = 0.90

* P < 0,05

and 2 were left-handed. The question remains whether the daily,more intensive use of the dominant hand resulted in improvedrecovery on this study. One of the limitations of the current studyis that is remains impossible to evaluate whether the medicationresulted in a more rapid improvement and a better result, incomparison to a natural recovery from an exacerbation.Nevertheless, it remains clinically relevant that the score forseveral functions and activities improved within 3 months.

The Patient Population in the SP phase of MS

For these patients, only the grip strength of the left handimproved significantly. All other functions of the movementsystem or movement activity remained unchanged for this patientgroup. A possible explanation for this finding might be thatpatients in this phase of the disease experience moreunsatisfactory results or unpleasant side effects ofMethylprednisolone and therefore decided not to pursuetreatment. A serious limitation of this study is its design: acomparison with a control group would be preferable, todetermine whether differences between the two groups exist.When our study results should be replicated in a controlled study,one can recommend not to continue the prescription ofMethylprednisolone to patients in the SP phase of MS, as itseems to be cost-ineffective for this patient group. Werecommend to investigate this topic more thoroughly in futureresearch.

Practical Implications

A physiotherapeutic measurement protocol seems to allowin-dept monitoring of the motor function of Methylprednisolone-treated MS patients. Scores on the various instruments providea good indication of the patient’s motor functioning. This isextremely relevant in daily clinical care. Performance of themeasurement protocol by the physiotherapist stimulatescooperation with other disciplines in the care for MS patients.Additionally, outcomes of the measurements can serve as aguideline in decision making about treatment.

Finally, the motor function, expressed in a number ormeasure, is considered very valuable by the patients. For thesereasons, we assume that the physiotherapeutic measurementprotocol has added value in the treatment of MS patients.

Acknowledgements

The authors would like to thank Biogen Idec, Inc. for thefinancial contribution for the English translation of this article.

Conflict of Interest

There is no conflicts of interest.

References

1. Minderhoud J. Multiple Sclerosis. Bohn Stafleu Van Lochem1999.

2. Lublin F. Defining the clinical course of multiple sclerosis.Neurology 1996; 46: 907-911.

3. Barnes D. Randomised trial of oral and intravenousMethylprednisolone in acute relapses of multiple sclerosis.The Lancet 1997; 349: 902-906.

4. Filippini G. Corticosteroids or ACTH for acute exacerbationsin multiple sclerosis. The Cochrane Library. 2000.

5. Hauser S. Intensive immunosuppression in progressivem.s. The New England Journal of Medicine 1983: 308: 173-180.

6. Comi G. Starting disease modifying treatment in ms. IntMSJ 2000; 7: 55-61.

118 Frank van Eijkeren / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

7. Rudick R. Multiple sclerosis therapeutics. Martin Dunitz Ltd.1999.

8. Durelli L. High-dose intravenous methylprednisolone in thetreatment of m.s.Neurology 1986; 36: 238-243.

9. Milligan N. A double blind contolled trial of high dosemethylprednisolone with m.s:clinical effects. Journal ofNeurology, Neurosurgery and Psychiatry 1987; 50: 511-516.

10. Sellebjerg F. Double-blind randomized, placebocontrolledstudy of oral, high-dose methylprednisolone in attacks ofm.s. Neurology 1998; 51: 529-534.

11. Goodkin D. A phase 2 study of i.v. methylprednisolone inspms. Neurology 1999; 52: 896-897.

12. Goodkin D. Upper extremity function in m.s.: assessmentwith Nine Hole Peg Test. Arch Phys Med Rehabil 1988; 69:850-854.

13. Rudick R. Recommendations from the National MultipleSclerosis Society Clinical Outcome Assessment Task Force.Ann Neurol 1997; 42: 379-382.

14. Thompson A. Multiple sclerosis: assessment of disabilityand disability scales. Journal of Neurology 1998; 245: 189-196.

15. Mathiowetz V. Reliability and validity of grip and pinchstrength evaluations. J Hand Surg 9A: 222-226, 1984.

16. Mathiowetz V. Grip and pinch strength: normative data. ArchPhys Med Rehabil 1985; 66: 69-74.

17. Bohannon R. Reference values for extremity musclestrength by dynamometry. Arch Phys Med Rehabil 1997;78: 26-32.

18. Andrews A. Normativ values obtained with hand-helddynamometers. Physical Therapy 1996; 76: 248-259.

19. Wade D. Measurement in neurological rehabilitation.OxfordUniversity Press. 1996.

20. Collen F. Mobility after stroke: reliability of measures ofimpairment and disability. Int Disabil Studies 1990; 12: 6-9.

21. Holden M. Gait assessment for neurologically impairedpatients.Physical Therapy 1986; 66: 1530-1539.

22. Mathiowetz V. Adult norms for the nine hole peg test offinger dexterity. Occup.Ther.J.Res. 1985a; 5: 24-38.

23. Berg K. Clinical and laboratory measures of posturalbalance in an elderly population. Arch Phys Med Rehabil1992; 73: 1073-1080.

24. Berg K. Measuring balance in the elderly: preliminarydevelopment of an instrument. Physiotherapy Canada1989; 41: 304-311.

25. Holden M. Clinical gait assessment in the neurologicalimpaired. Physical Therapy 1984; 64: 35-40.

119

Test-retest Reliability of the Onset of Lower Limb Muscles’Preactivation During Landing from A Jump in Volleyball PlayersWith Functional Ankle InstabilityMohammad Sadeghi Goghari1, Smaeil Ebrahimi2, Nader Maroufi3, Ali Ashraf Jamshidi4

1PhD student of Physical Therapy, 2Professor of Physical Therapy, 3Assistant Professor of Physical Therapy, 4Faculty of RehabilitationSciences, Tehran University of Medical Sciences, Tehran, Iran

Mohammad Sadeghi Goghari / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

The Abnormal timing of muscle preactivation during landingfrom a jump may be one of the main mechanisms of ankleinstability in volleyball players. Thus, the purpose of this studywas to investigate the test-retest reliability of the onset timing oflower limb muscles’ preactivation during landing in volleyballplayers with functional ankle instability (FAI).Eighteenprofessional volleyball players with unilateral FAI participated inthis study. They performed four jump-landing trials in forwarddirection and the reliability of the onset time of five lower limbmuscles’ preactivation including gluteus maximus(G.max),gluteus medius(G.med),vastus medialis(VM), peroneuslongus(PL) and medial gastrocnemius (MG) was assessed usingIntraclass correlation coefficients (ICC), standard errors ofmeasurement (SEM) and co-efficient of variation (CV) after oneweek interval. During the jump-landing task, high and very highreliability was found for G.max, G.med, VM, PL, MG onset timesof preactivation with ICC level of .80, .72, .92, .91 and .80respectively. The CVs of all onset times of muscle preactivationwere less than 10% except for G.med and MG (14.72% and11.50% respectively).The EMG onsets during landing had highto very high reliability and these parameters were found to beuseful in the assessment of timing patterns in subjects with FAI.

Key Words

Reliability, Preactivation, Landing, Ankle Instability.

Introduction

In sports such as volleyball, the ankle sprain frequentlyoccur because it involve jumping and landing with high groundreaction forces, resulting in lateral ankle sprain rate of 87%1.Following an acute lateral ankle sprain, the most commondebilitating condition is functional ankle instability (FAI) that it isdeveloped in 15-60% of cases2. The Main sign of the FAI isfeeling of instability combined with episodes of the ankle givingway during sport activities or during the simple act of walking.

The neuromuscular mechanisms behind the pathology ofankle instability are unknown. Therefore, evaluating muscleactivation pattern during dynamic activities, such as landing,may help elucidate the mechanism of disorder. There is evidenceto suggest that pre-programmed motor plans may be altered inindividuals with FAI, predisposing them to ankle inversionmoments3, 4. The muscle preactivation in the aerial phase ofjump-landing is a measure of the feedforward mechanism ofcentral nervous system to control the stability of lower limb joints5.Furthermore, the effect of these altered open-loop controlstrategies should be evaluated.

Reliability refers to the extent to which a measurement isinherently reproducible, or the degree to which a measurementis influenced by measurement errors6, 7. In this regard, theStability of a performance variable can be assessed by test-retest reliability methods across repeated trials over time8.

If electromyography (EMG) parameters are used fordiscriminative and evaluative purposes, determining of themeasurement error is a major concern. Intrinsic and extrinsicfactors along with variability of EMG signal are potential sourcesthat may subject the EMG to measurement error. To our

knowledge, no work to date has evaluated reproducibility of thetiming of muscle preactivation during landing from a jump involleyball players with FAI. Thus, the purpose of this study wasto investigate the test-retest reliability of the onset timing of lowerlimb muscles’ preactivation during landing in volleyball playerswith FAI.

Methods

Subjects and Study Design

Eighteen male volleyball players with unilateral FAI (age:23±2.8 years; height: 189.18 ±6.36 cm; body mass: 81.87±7.71kg) participated in this study. All the study subjects were membersof different teams of Volleyball League First Division in Iran. Tobe characterized as having unilateral FAI, the subjects satisfiedthe following criteria: (1) having at least one significant lateral(inversion) ankle sprain of either the right or left ankle, but notboth, in which the subjects were unable to bear weight or wereplaced on crutches, within the last year; (2) having at least tworepeated injuries or the perception of ankle instability or givingway in either the right or left ankle, but not both; (3) showing noevidence of mechanical instability ,as assessed using as anteriordrawer and talar tilt tests; and (4) not having participated in arehabilitation program. All the subjects were pain free and fullweight bearing at the time of the study and they were examinedby the same clinician to exclude cases with neurological orvestibular impairment, past orthopedic surgery or fracture.Subjects gave their informed consent to the experimentalprocedure, and the study was approved by the ethics committeeof Tehran University of Medical Sciences.

Procedure

Subjects were referred to the research laboratory for thetesting procedures. First, an assessment of vertical jump heightwas performed to determine the target for the subjects duringjump-landing trials. Maximum vertical height (vertmax) wasdetermined as the difference between the maximum heightreached during the three maximal double-limb vertical jumpsand standing-reach height; this value was used to designate atarget for the subjects to reach during the jump-landing trials1, 9.

Immediately after vertmax testing, the jumping-landing taskwas demonstrated to the subjects for them to be familiarizedwith the task. The jumping-landing task consisted of a double-limb countermovement jump with landing on a single limb inforward direction. To adjust jump height tantamount to 50%vertmax, two vertical wooden bars were placed on either side ofthe force plate that was connected to each other’s by a tape. Tobegin the task, each subject stood 70 cm away from the centerof the force plate and jumped with both legs toward the centerof the plate. Subjects were asked to reach up and touch thetape indicating 50% of the Vertmax with their dominant hand beforelanding on the force plate. They were also required to land onthe stance leg, and stabilize as quickly as possible, and assumea single leg stance position with their hands on their hips whilefacing straight ahead1, 9. The stance leg is defined as the legwith functional instability. Each subject performed four trials ofjump-landing in each session. In order to prevent fatigue while

121Mohammad Sadeghi Goghari / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

The number of trials averaged and used for data analysismay affect reliability as well. Greater number of trials may displayless variability. In the present study, each subject performedfour trials of jump-landing in forward direction and the mean ofthem were calculated for the assessment of reliability. In thebasis of ICC analysis, Roger James at el indicated that anaverage of four trials were necessary to achieve maximum ICCvalues8.

Caution should be taken when comparing results fromreliability studies examining well-learned activities with the studyresults where a newly learned or less commonly performedactivity is examined. In our study, trained male athletes used toassess the reliability of EMG onset time during jump-landing.All participants were professional volleyball players who wereperforming repetitive jump-landing in practices and competitions.Therefore, they were familiar with the tasks. Ortega at el.mentioned that volleyball involves approximately 60 maximaljump-landing per hour in a game and a volleyball team in theUnited States perform 300 to 500 jumps in a four-hour sessionof training15. This point may be one of the main reasons of theexcellent reproducibility of the measures in this research.

The kinematics and pattern of motion in jump-landing maybe a source of variability of onset times and affect reliability.Thus, standardization of the task in test and retest sessionsshould be take into consideration. In this research, subjects wereasked to reach up and touch a tape indicating 50% of the Vertmaxwith their dominant hand before landing on the force plate 1, 9.

The most common methods of analyzing absolute reliabilityare the SEM and the CV. They provide an indication of thevariability and an estimation of measurement error in repeatedmeasurements6, 7.Some authorities have arbitrarily selected ananalytical goal of the CV being 10% or below, but they are notconsensus on it6. The CVs of all onset times of musclepreactivation were less than 10% except for G.med and MG(14.72% and 11.50% respectively). Nevertheless, thesemeasures seem to be less suitable than others for clinicalassessment but they lie within our arbitrary benchmarks.

It is difficult to compare the results of this study with previousinvestigations because, to our knowledge, this research is thefirst study which reported the reliability of EMG onset of lowerlimb muscles in a jump-landing task. Some previous studieswitch evaluated the onset times during landing task did not reportmeasurement reliability in their papers.

Certainly, this study has its own limitations. In our study,only one examiner measured, processed and analyzed the EMGdata; therefore, our finding may only be applicable to singleexaminer (intra-rater reliability) studies and is not suitable forstudies evaluating reliability with more than one examiner (inter-rater reliability).

Another possible limitation associated with our study maybe movement of the electrodes over the skin since the jump-landing task was dynamic; hence, we tried to avoid moving theelectrodes on the skin with using double adhesive tape as faras possible.

The Findings of presence study have important applicationsfor both clinicians and researchers. Reliable determination ofthe motor control of lower limb muscles during a jump-landingtask might help clinicians to realize abnormal or compensatorystrategies that may be unique to athletes with FAI and increasethe efficiency of rehabilitation.

Conclusion

Results of this study showed acceptable reliability of theEMG onset times during the jump-landing task. So, the onsettime measurement may be applicable in evaluation of motorcontrol and treatment of athletes with FAI. Since reliability is

population dependent and is not a fixed property, the results ofeach research can be generalized only to the same targetpopulation, not to other ones. Thus, it is unknown if similar ICCswould be obtained using other methodologies.

Acknowledgement

This research was supported by grants from the TehranUniversity of Medical Sciences. The experiment was conductedin Biomechanics Lab., Rehabiliation Research Centre, TehranUniversity of Medical Sciences.

References

1. Shaw, M.Y., Gribble, P.A. and Frye, J.L. Ankle bracing,fatigue, and time to stabilization in collegiate volleyballathletes. J Athl Train 2008; 43(2):164-71.

2. Yuri suda, E., Amorim, C. and Neves Sacco, I. Influence ofankle functional instability on the ankle electromyographyduring landing after volleyball blocking. J ElectromyogrKinesiol 2009; 19(2): e84-e93.

3. Caulfield, B. and Garrett, M. Changes in ground reactionforce during jump landing in subjects with functionalinstability of the ankle joint. Clin Biomech 2004; 19(6): 617-621.

4. Gribble, P. and Robinson, R. Differences in spatiotemporallanding variables during a dynamic stability task in subjectswith CAI. Scand J Med Sci Sports 2010; 20: e63-e71.

5. Fu, S.N., and Hui-Chan, C.W. Modulation of prelandinglower-limb muscle responses in athletes with multiple anklesprains. Med Sci Sports Exerc 2007; 39(10): 1774-83.

6. Atkinson, G. and Nevill, A.M. Statistical Methods forAssessing Measurement Error (Reliability) in VariablesRelevant to Sports Medicine. Sports Med 1998 Oct; 26(4):217-238.

7. Bruton, A., Conway, J.H., and Holgate, S.T. Reliability: whatis it, and how is it measured? Physiotherapy 2000; 86(2):94-99

8. Roger James, C., et al. Number of trials necessary toachieve performance stability of selected ground reactionforce variables during landing. J Sports Sci Med 2007; 6:126-134.

9. Wikstrom, E.A., Powers, M.E., and Tillman, M.D. DynamicStabilization Time After Isokinetic and Functional Fatigue.J Athl Train 2004; 39(3): 247-253.

10. Santello, M., and McDonagh, M.J. The control of timingand amplitude of EMG activity in landing movements inhumans. Exp Physiol 1998; 83(6):857-74.

11. Mathur, S., Eng, J.J., and Macntyre, D.L. Riliability of surfaceEMG during sustained contractions of the quadriceps. JElectromyogr Kinesiol 2005; 15:102-110.

12. Cowan, S.M., Bennell, K.L., and Hodges, P.W. The test-retest reliability of the onset of concentric and eccentricvastus medialis obliquus and vastus lateraliselectromyographic activity in a stair stepping task. PhysicalTherapy in Sport 2000; 1: 129-36.

13. Zuniga, E.N., Truong, X.T., and Simons, D.G. Effects ofskin electrode position in averaged EMG potentials. ArchPhys Med Rehabil 1970; 51:264-72.

14. Kramer, H., Kuchler, G., and Brauer, D. Investigations ofthe potential distribution of activated skeletal muscles inman by means of surface electrodes.Electromyogr ClinNeurophysio 1972; 12:19-26.

15. Ortega, D.R., Rodriguez Bies, E.C., and Berral de la Rosa,F.J. Analysis of the vertical ground reaction forces andtemporal factors in the landing phase of a countermovementjump. J Sports Sci Med 2010; 9:282-287.

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Evaluation of Wet Cupping Therapy (Hijama) as an AdjuvantTherapy in the Management of Bronchial AsthmaMohamed Elsayed Mohamed Abd al-Jawad1, Adel Mohamed Saeed2, Ahmed Elsayed Badawy3, NevineM Mohamed Abd Elfattah2

1Department of Chest, Giza Chest Hospital, Giza, Egypt, 2Department of Chest, Faculty of Medicine, Ain Shams University, Cairo,Egypt, 3Department of Pharmacology, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Mohamed Elsayed Mohamed Abd al-Jawad / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

The aim of this study is to evaluate the effectiveness ofcupping therapy as an adjuvant therapy in the management ofpatient with bronchial asthma. To achieve this target, a total of50 patients suffering from moderate persistent bronchial asthmawere included in this study. They were selected from chest clinicsin Giza Chest Hospital and Ain Shams University Hospital.

Patients were selected according to positive history ofasthma, and other clinical examinations. They were divided intotwo randomly equal matched groups, 25 patients each, accordingto the time of attendance to the outpatient clinic.

Group I: 25 patients each subjected to complimentarycupping therapy besides the conventional medication set byGlobal Initiative For Asthma 2006.

Group II: 25 patients each received conventional medicationonly set by Global Initiative For Asthma 2006. The conventionaltreatment is recommended by GINA 2006.

All our patients were subjected to clinical evaluation(daytime symptoms, nocturnal symptoms, need for rescuemedications , limitation of activity and exacerbations) andrespiratory function tests before and after 3 months of treatment.In addition to serum ECP were measured using IMMULITE/IMMULITE 2000 Analyzers and complete blood picture withemphasis on esinophilic count at base line before and after 3months of treatment, as well as just before and after the 1st and3rd cupping sessions.

In the present study, we found that there was clinicalimprovement of highly significant statistical value in both groups,however, group (I) showed better response regarding all clinicalparameters. Regarding the improvement in the pulmonaryfunction tests before and after treatment in both groups therewas statistically significant difference in the improvement in group(I) compared to group (II) especially as regard FEV1, FEV1 \FVC% and FEF25 – 75 %. Regarding relative esinophilic countin peripheral blood film before and after 3 months’ treatment,there was statistical significant reduction in group (I) and nonsignificant statistical reduction in group (II) , but as a salientfeature , there was significant statistical reduction in esinophiliccount in group (I) after as compared to before the 1st session(30 minutes average). Regarding serum ECP levels of venoussample before and after 3 months’ treatment there was significantstatistical reduction in serum ECP levels in the group (I), andnon significant statistical reduction in group (II). Regardingcomplete blood picture CBC results (hemoglobin % , RBCs count, WBCs and platelets) of venous samples drawn from all patientsbefore and after cupping in group (I) showed non significantdifferences in them. On the other hand there was significantstatistical difference between cupping and venous samplesregarding the platelet count where the platelet count of thecupping blood was less than the platelet count of the venoussample. Therefore cupping is considered as a filter to keep thebeneficial elements to the body and get red of the harmfulelements . In the present study in comparison between the twogroups after the period of 3 months treatment it was found thatgroup (I) had a significant statistical difference than group (II) asregard daytime symptoms, nocturnal symptoms, need forreliever, exacerbations, ECP, Peripheral Esinophilic count, FVC

% and FEF25%-75%.On the other hand a high significantstatistical difference as regard FEV1/FVC% and FEV1 % wasfound.

Key Words

Islamic medicine, Prophetic Medicine , complimentarymedicine, cupping therapy, wet cupping therapy, Hijama,bronchial asthma, blood esinophilic count, serum ECP,pulmonary functions.

Introduction

Asthma (from the Greek Üóèìá, ásthma, “panting”) is thecommon chronic inflammatory disease of the airwayscharacterized by variable and recurring symptoms, reversibleairflow obstruction, and bronchospasm1. Symptoms includewheezing, coughing, chest tightness, and shortness of breath2.Asthma is clinically classified according to the frequency ofsymptoms, forced expiratory volume in 1 second (FEV1), andpeak expiratory flow rate3. Asthma may also be classified asatopic (extrinsic) or non-atopic (intrinsic)4.

Inspite of laudable efforts to improve asthma care over thepast decade, a majority of patients have not benefited fromadvances in asthma treatment and many lack even the rudimentsof care5.

The use of CAM in asthma patients is increasing as anadjunct and also as a substitute for effective and proventherapies6.

The three methods of healing known to have beenmentioned by the medical advice of Muhammad ( r ) were honey,cupping, and cauterization, though he was generally opposedto the use of cauterization7.

Cupping is used to treat asthma, common cold, chroniccough, indigestion problems, and skin conditions8. Cupping isbeneficial for dry coughs, asthma, rheumatism, localizedswellings, and pain9.

Subjects and Methods

This work had been carried out at Giza Chest Hospital andAin Shams University Hospital, in a seven months period fromFebruary to August 2008.

Patients were provided with information sheets detailingthe research procedure, subject understanding of the researchwas considered and a consent form was provided prior tocommencing the study.

This study included 50 asthmatic patients selected fromchest clinics in Giza Chest Hospital and Ain Shams UniversityHospital. They were diagnosed clinically according to the reviseddiagnostic criteria set by (GINA, 2006) that included :

Measurements of lung function provide an assessment ofthe severity, reversibility, and variability of airflow limitation, andhelp confirm the diagnosis of asthma.

The patients studied were divided into two randomly equalmatched groups, 25 patients each, according to the time ofattendance to the outpatient clinic.Group (1): (combined treatment group) Included 25 asthmaticpatients suffering from moderate persistent bronchial asthmasubjected to complimentary cupping therapy besides the

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conventional medication set by Global Intiative For Asthma2006.

Group (2) : (medically treated group as control) Included25 asthmatic patients suffering from moderate persistentbronchial asthma received conventional medication only set byGlobal Intiative For Asthma 2006.The treatment is recommendedby GINA 2006.

All patients were subjected to the following

1. Medical history: (history of episodic breathlessness,wheezing, cough, and chest tightness. Episodic symptomsafter an incidental allergen exposure, seasonal variabilityof symptoms and a family history of asthma and atopicdiseases).

2. Clinical examination: (complete general and local chestexamination especially auscultation of wheezes orprolonged expiration on quite or forced exhalation).

3. The number of exacerbations during the treatment.4. How many times the patient needed relieve medications?5. Was there any Limitation of activity ?6. How many times asthma awakened the patient at night?7. X-ray chest to exclude any local chest diseases .8. ECG in selected cases to exclude cardiac problems .9. Spirometric study were performed using the computerized

spirometry (DATOSPIR mod. 120C).10. Laboratory studies:a. Complete blood picture (CBC): with emphasis on esinophilic

count for the blood coming from cupping therapy (cuppingblood) and (2 venous blood samples) before and aftercupping in the same cession of the cupping.

♦ Serum Esinophilic Cataionic Protein (ECP) :measurement in the serum of the blood coming fromcupping therapy (cupping blood) and (one venous bloodsample before cupping in the 1st session and after cuppingin the 3rd session).

♦ N.B : Steps 9 and 10 were repeated after 3 months oftreatment.

Exclusion Criteria

♦ Smokers.♦ Patient’s refusal or lack of cooperation.♦ Patient with major organ dysfunctions ( e.g. cardiac ,

respiratory, hepatic, renal, or other significant systemicdisorders ).

♦ Local sepsis or systemic septicemia.♦ Overt coagulopathy or patients on coagulant therapy that

contraindicate cupping therapy.♦ Any neuro – psychiatric deficits.♦ Parasitic infestation.♦ Alternative causes of recurrent wheezing must be

considered and excluded as gastroesophageal reflux,recurrent viral lower respiratory tract infections ,tuberculosisand foreign body aspiration.

Specimen Collection and Preparations

1. Serum

Blood samples were collected by venipuncture with 5 mldisposable syringes into a clean, dry centrifuge tubes andallowed to stand at room temperature for about 30 minutes,then centrifuged at 5000 r. p. m for 10 minutes.

Serum was separated from the cells and was stored inepindorff tubes in deep freeze at - 20C for the Quantitative

measurement of esinophilic cationic protein ( ECP) in serumusing IMMULITE / IMMULITE 2000 Analyzers.

2. Whole blood

For the complete blood picture determination, whole bloodwas withdrawn into clean plastic tubes containing EDTA andwell shaken.

Bloodletting Cupping Therapy

A specific protocol for medical bloodletting cupping therapywas applied according to the modern bloodletting cuppingprocedure10.

Patients of group (I) were subjected to bloodletting cuppingon 3 basic points which were selected according to traditionalArab medicine :• The first point is : “ AI-Kahel “ between shoulders (7th

cervical spine) where Ibn Al-Koff stated that cupping on itcomfort dyspnea11.The second and third points are : on the region between

the two shoulder – blades where Ibn Sina stated that the cuppingon it can comfort dyspnea and asthma11.

The Procedure of Bloodletting Cupping

A high quality and durable cupping set was used figure(4). It has a vacuum pump (suction pump) and cups whichwere lightweight, break resistant and anti – aging plastic.These cups were supplied in different sizes and comeswith a detailed user’s manual which I had followed exactly:

1. It was made sure the inside of the cup is clean and thehandle is completely unfastened .

2. The skin of the patient must be dried , cleaned by antisepticsolution and the hair is shaved in the selected area of theskin for ideal maximum performance of the cups.

3. An appropriate size or type of cup was selected . The cupwas put on the selected previous three points. With the rimof the cup facing downward, press tightly with one handand screw the handle of the vacuum with the other until thecup sucks onto the skin.

4. The handle of the cup was screwed or unscrewed to adjustthe pressure inside the cup.

5. The cups were left for few minutes until the skin engorged.6. The selected points were scarified very superficially .7. The cup was put on the selected previous three points again

and the handle of the cup was screwed or unscrewed toadjust the pressure inside the cup.

8. The cup was removed when was one to two thirds full andanother cup was set on the spot.

9. The cupping procedure was repeated until the scarificatedindurations bleeds no more.

10. The cups were unscrewed after the desired elapsed time.11. The small wound is gently rubbed with an antibiotic ointment

and then covered with a sterile bandage that would be leftfor one day.

Results

This table shows that group (I) had a significant statisticaldifference (p>0.05) as regard daytime symptoms, nocturnalsymptoms, need for reliever, exacerbations, ECP, peripheralesinophilic count, FVC % and FEF25%-75% , than group (II)after 3 months of treatment , as well as a highly significantstatistical difference (p > 0.01) as regard FEV1 % and FEV1/FVC%.


124 Mohamed Elsayed Mohamed Abd al-Jawad / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Table 1: Comparison between the two groups after 3 months of treatment as regard daytime symptoms, nocturnal symptoms, needfor reliever, exacerbations, ECP, peripheral esinophilic count, FEV1 %, FVC %, FEF25%-75% and FEV1/FVC% after the period oftreatment.

Parameters Group ( I ) Group ( II ) T P value Sig. After Mean± SD Mean± SD

Daytime symptoms 1.64 ± 2.03 3.36 ± 3.03 2.35 < 0.05 S

Nocturnal symptoms 0.64 ±1.11 1.80± 1.97 2.55 < 0.05 S

Need for reliever 1.36 ±1.31 3.08 ±2.25 3.29 < 0.05 S

Exacerbations 0.04±0.2 0.28 ±0.45 2.4 < 0.05 S

ECP 36.36 ± 27.86 48.31 ±9.86 2.02 < 0.05 S

Peripheral Esinophilic 1.68 ±0.62 3.60±3.10 3.02 < 0.05 Scount

FEV1 % 84.4 ±6.93 70.68 ±8.97 6.04 < 0.01 HS

FVC % 96.80 ±2.92 94.64 ±3.12 2.52 < 0.05 S

FEF25%-75% 59.88 ±6.60 53.46±12.68 2.24 < 0.05 S

FEV1/FVC% 78.32 ±8.56 65.24 ±9.97 4.97 < 0.01 HS

Table 2: Comparison of the two groups as regard limitation of activity after 3 months of treatment.

Group I Group II X2 P Sig.Case ControlN=25 N=25

Limitation 0 19 10 6.66 < 0.05 SAfter 1 3 7treatment 2 3 8

0 = non. 1 = minor limitation. 2 = some limitation.This table shows that group (I) had a significant statistical difference than group (II) as regard the limitation of activity.

Fig. 1: Comparison between the two groups after 3 months of treatment as regard daytime symptoms , nocturnal symptoms, needfor reliever, exacerbations and peripheral esinophilic count.

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Fig. 3: Comparison between the two groups after 3 months of treatment as regard limitation of activity after 3 months of treatment.

Table 3 : Comparison between venous and cupping samples as regard platelets count in the 1st and 3rd cupping sessions amonggroup (I).

Venous sample Cupping sample T p Sig.

Platelets 277.8±74.7 139±72.46 6.2 < 0.01 HS(before treatment)

Platelets 263.7±65.7 80.8±55.14 9.36 < 0.01 HS(after treatment)

This table shows a highly significant statistical difference between venous sample and cupping sample as regard platelets in the 1st

and 3 rd cupping sessions.

Fig. 2: Comparison between the two groups after 3 months of treatment as regard ECP , FEV1 % , FVC % , FEF25%-75% andFEV1/FVC%.

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Fig. 4: The cupping set.


Conclusions

Finally We Can Conclude That

1. Cupping therapy may be an adjuvant therapy in treatmentof bronchial asthma.

2. Cupping therapy play an important role in improving bothpulmonary functions of asthmatic patients and symptomsrelief, as well as act as an anti inflammatory factor in asthmaby decreasing peripheral esinophilic count and serum ECP.

3 Cupping has the ability to help tissues to get red of toxinsand considered as a filter to keep the beneficial elementsto the body.

4. CAM is economic , practical and easy to apply as a commonpractice in medicine.

5. Cupping therapy is simple procedure , and may be effectivein treatment of bronchial asthma.

6. The procedure of cupping doesn’t seem to be harmful ifdoneappropriately.

7. There are many CAM treatments for which benefits forhealth are claimed. However, it is important to find out whatscientific studies have been done on the safety andeffectiveness of the CAM treatment.

Interest of Conflict

None.

Acknowledgement

All praise is due to Allaah Subhanahu Wa Ta’ala, wepraise Him and seek His aid and forgiveness.

I am grateful to all my colleges, nurses and technicians atGiza Chest Hospital.

I want also to thank Marketing Institute For ScienceResearches (MISR) for their scientific co operation .

Thanks are also due to the members of the InternationalCommission on Scientific signs in the Qur‘an & the Sunnah fortheir generous attitude to my project .

Lastly a lot of thanks to my parents, my wife and mydaughters (Habyba & Mariam) for their tolerance, continuoussupport and encouragement.

References

1. NHLBI 2007 p.11–122. BTS 2009 p.33. Yawn, BP (September 2008). “Factors accounting for

asthma variability: achieving optimal symptom control forindividual patients”. Primary Care Respiratory Journal 17( 3 ) : 1 3 8 – 1 4 7 . d o i : 1 0 . 3 1 3 2 / p c r j . 2 0 0 8 . 0 0 0 0 4 .PMID 18264646. http://www.thepcrj.org/journ/vol17/17_3_138_147.pdf.

4. Kumar, Vinay; Abbas, Abul K; Fausto, Nelson; Aster, Jon(2010). Robbins and Cotran Pathologic Basis of Disease(8th ed.). Saunders. p. 688. ISBN 9781416031215

5. Global Initiative For Asthma (GINA) (2006): Global StrategyFor Asthma Management and Prevention available from:http://www.ginasthma.org.

6. Ernst E. Complementary therapies for asthma: whatpatients use? J Asthma 1998; 35 : 667–71.

7. Nurdeen Deuraseh, “Ahadith of the Prophet (s.a.w) onHealing in Three Things (al-Shifa’ fi Thalatha): AnInterpretational”, Jounal of the International Society for theHistory of Islamic Medicine, 2004 (3): 14-20 [18].

8. Abele J. Cupping ; a reliable alternative healing method.Translation of the German book from Dr . med . JohannAbele BY Um Yasin Ahmed Hefiny . Gustav Fischer , UlmStuttgart Jena Lubeck : ISBN 3-437-55171-X ; 1998.

9. Jin C , Guangqi Z . A survey for Thirty Years ClinicalApplication Of Cupping, Journal Of Traditional ChineseMedicine 9 (2) : 151 – 154 .

10. Chirali I Z . Traditional Chinese Medicine: Cupping Therapy;Churchil Livingstone ; 1999 .

11. Bondok S M. Cupping the great missing therapy ,1st ed,Dar Al-Salam foundation : Cairo ; 2007 .

127Mullai Dhinkaran / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Comparative Analysis of Muscle Energy Technique andConventional Physiotherapy in Treatment of Sacroiliac JointDysfunctionMullai Dhinkaran1, Aarti Sareen2 Tanu Arora3

1Assistant professor, College of Physiotherapy, 2Graduate, Bachelor of Physiotherapy, 3Demostrator, College of Physiotherapy,Christian Medical College & Hospital, Ludhiana

Abstract

Purpose of Study

Lumbar manipulation and conventional physiotherapy, bothhad reported significant results for low back pain (LBP) due tosacroiliac joint dysfunction (SIJD). In lumbar manipulation,Muscle Energy Techniques (MET) is frequently used for painrelief and increase range of motion. MET is an active techniquein which the patient voluntarily contract specific muscle againstthe resistance of clinician. Unfortunately, no study has examinedthe effectiveness of MET in comparison to conventionalphysiotherapy.

Material and Method

This study was to compare the MET and conventionalphysiotherapy in treating low back pain due to SI jointdysfunction. It was a comparative study in which 30 subjectswere recruited from Department of Physiotherapy, ChristianMedical College and Hospital, both male and female agebetween 18-35 years complaining of low back pain (more than3 months) due to SI joint dysfunction (anterior innomiate type)andfulfilling the inclusion and exclusion criteria were taken. Oswestrydisability index (ODI) and numeric pain rating scale (NPRS)reading were taken before the treatment. Subjects randomlygrouped into 2 groups, Group A (n=15) (MET & correctiveexercises were given) Group B (n=15) (TENS & correctiveexercises were given). Total 6 treatment sessions were givenand then the ODI & NPRS readings were taken at the end totreatment sessions (6th day of treatment).

Result

After data analysis with student’s ‘t’ test the mean difference± standard deviation for ODI relief (%) for Group A and Group Bwere 7.49 ± 5.709 and 7.49 ± 3.391 and that for numeric painrating relief for Group A and Group B were 0.80 ± 0.737 and0.8. ± 0.507. The average of Oswestry Disability Index (%) reliefdecrease for Group A is 27.15% and for Group B it is 19.67%and the average of numeric pain rating scale relief for GroupA is 3.40and for Group B is 2.60.

Conclusion

The result of the study showed that along with correctiveexercises, MET is moderately significant over conventionalphysiotherapy i.e. TENS with corrective exercises in improvingfunctional ability and decreasing pain.

Key Words

Sacroiliac joint dysfunction (SIJD), Low back pain (LBP),Muscle energy techniques (MET), Transutenous electrical nervestimulator (TENS).

Introduction

Most common source of low back pain is SI dysfunction, acondition presumed to be caused by acquired mechanicalinstability, with no history of major trauma, which leads to eitherfixed subluxation or hyper mobility of the joint1-2.The cause ofsacroiliac joint dysfunction is likely in the correlative movementsof the sacroiliac joints (either too much or too little movement inthe joint or assumption of an antagonistic position by theinnominate bones when they normally should be symmetrical).Extensive analysis and computation in a recent study,

Lavignolle et al concluded “the sacroiliac joints remain quitea mystery and knowledge of their precise mode of function isstill incomplete 3.Wilson Eric et al study 10 men and 9 womendiagnosed with acute low back pain were randomly assignedwith stratification to 1 of 2 treatment groups. Patients werematched according to age, gender and initial oswestry score.They concluded that MET combined with supervised motorcontrol and resistance exercises may be superior toneuromuscular re-education and resistance training fordecreasing disability and improving function in patients with acutelow back pain. In this was not discussed about causes of lowback pain4.

Richard L DonTigny describes the biomechanics andfunction of the sacroiliac joint, the dysfunction andpathomechanics of sacroiliac joint as a common cause of lowback pain. Dysfunction of sacroiliac joint is a commonbiomechanical lesion, which is frequently brought on insidiously,is related to in quality of leg length, pelvic torsion, and pelvicobliquity, is described as increased pain on sitting, leaningforward, coughing or sneezing and is associated with pain onpassive SLR and pain during pregnancy. Correction andprevention of SI joint dysfunction is quiet simple and effective.The treatment for correction and prevention of SI joint dysfunctionis corrective exercise program, use of corrective corset support,heel lifts therapy and transcutenous electrical nerve stimulator(TENS) with corrective exercises5.

In lumber manipulation muscle energy techniques (MET)is one of the commonest treatments of choice for the pain reliefand to increase range of motion 3. Muscle energy techniquesare a class of soft tissue manipulation methods that incorporateprecisely directed and controlled, patient initiated, isometric and/or isotonic contractions, designed to improve musculoskeletalfunction and reduce pain3.

For many years, MET has been advocated to treat muscleimbalances of the lumbopelvic region such as pelvisasymmetry. The theory behind MET suggests that techniqueis used to correct an asymmetry by targeting a contraction ofthe hamstring or the hip flexors on the painful side of the lowback and moving the innominate in a corrected direction6.

There are many researches on the individual treatmentoptions as of the conservative managements are always givenpreferences in comparison to the non conservative implicationsor surgical interventions, but their was no comparative studyor to check a better treatment option out of two. After the studythe effectiveness and the most preferred treatment option wouldbe clear as if TENS with corrective exercises is good option orMET with corrective exercises in pain due to SI joint dysfunction.

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Methodology

Subjects 30 were selected according to the inclusion andexclusion criteria, Department of Physiotherapy, ChristianMedical College and Hospital, Ludhiana. The study design wasRandomized controlled trial with simple random samplingtechniques. The independent variables were Muscle energytechniques, Transcuteneous electrical nerve stimulation,Corrective exercise. The dependent variables were Numeric painrating scale, Oswestry Disability index.

Patients complaining of chronic low back pain (of more than3 months) were properly assessed for sacroiliac joint dysfunction(of anterior innomate dysfuncation type) i.e. whether the pain islumbopelvic pain in origin. Tests used to diagnose the SIJD werethe common tests include determination of posterior superioriliac spine (PSIS) level in a standing or sitting position, the Gillettest (also known as the march or stork test), the standing flexiontest, the sitting flexion test (or Piedallu’s sign), and the supine-to-sit test6,17,21.

Inclusion criteria were age group 18- 35 years, Both maleand female, Chronic low back pain for more than 3 months,Pain on performing pain provocative tests for sacroiliacdysfunction, Oswestry disability index above 20% but below80%, BMI was 25-29.9 kg/m2. The exclusion criteria wereparticipants suffering from specific low back pain like PIVD withinstability or any radicular symptoms, lumbar spondylosis,lumbarcanal stenosis, spondylolisthesis, sensory deficits,malignancies and tuberculosis Any traumatic conditions aroundthe pelvis and lower limbs, any infectious, tumors conditionsaround the pelvis, Cardiac pacemakers, thrombosis, recenthaemorrhage, Associated neurological symptoms, Patient whodo not understand the study/non co-operative, Pregnancy, anylower limb abnormalities, any recently underwent abdominal andlow back surgery.

Procedure

30 patients were taken on the basis of inclusion andexclusion criteria from department of physiotherapy, ChristianMedical College and Hospital. They were divided into 2 groups,Group A and Group B each consisting of 15 patients. All of themwere asked to sign the consent form after explaining the nature,aim and objectives of the research and the complete treatmentthey will be undergoing.

Before giving the treatment the pain rating according tonumeric pain rating scale and Oswestry disability index alongwith the complete assessment was recorded. Group A were givenmuscle energy technique with corrective exercises

Group B were given transcutaneous electrical nervestimulation with corrective exercises. Subjects in Group A weretreated with MET for the anterior innominate dysfunction theywere having .In the anterior innominate dysfunction ASIS isinferior, PSIS superior whereas in posterior innominatedysfunction ASIS is superior, PSIS inferior.

Patient is in prone and the therapist stands at the side tobe treated at the waist level. The affected leg and hip are flexedand brought over the edge of the table. The foot/ ankle area isgrasped between the therapist’s leg. The treatment site handstabilize the sacral area while other hand support the flexedknee and guides it into greater flexion, inducing posterior iliacrotation, until the restriction barrier is sensed. By palpating thesacral contact hand or by virtue of a sense of greater effort inguiding the flexed leg, and observation of pelvic movement asthe barrier of the resistance is passed. Once, the barrier isengaged the patient is asked to attempt to straighten the legagainst unyielding resistence, for 10 seconds using no morethan 20% of the available strength. On releasing the effort andon complete relaxation and on exhalation, the leg/innomiated isguided through its new barrier. These movements are repeated3 times until no further gain in the range of motion is possible6.

Mullai Dhinkaran / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Fig. 1: Anterior innomiate rotation correction with Muscle energytechnique

Conventional TENS, parameters between 50-100 Hz and100-200 µs are considered to be effective in the treatment ofchronic low back pain 7.

Subjects in group B were made to lie prone and TENS wasgiven. Our protocol used stimulation given in continuous trainsat high frequency (80 Hz, using square wave 100µs pulses).Patient lies in prone lying and two surface electrodes (5cm x 5cm2) were placed in or adjacent to the painful area at a distanceof 5 cm- 20 cm apart. The intensity of TENS was adjusted toproduce a tingling sensation 8.Following the MET and TENStreatment corrective exercises were performed by the patientunder the supervision of the therapist and one set of exercisesat home which includes 9.

Patient is asked to flex the hip and bring the knee into theipsilateral axilla from a supine, sitting or standing position. Thisis done 2-3 times.

Patient lies supine, grasp the hands around one knee andpull with the hands while pushing with the knee. This must bedone 2-3 times on each side, alternating each time with otherknee and should be repeated 15 or 20 times a day for about aweek.

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• Abdominal strengthening exercises with bent knee sit ups.This is done 10 times.

• Isometric abdominal exercises with 5 sec. hold and is done10 times.

• Following ergonomic advice was given to the patients whoshould be followed strictly during the whole treatment plan.

• Have a pillow placed between the knee when side lying.• Have a pillow placed under the lower edge of the buttocks.• Prone lying should not be done for one week of treatment

protocol.• All leg raising exercises should not be done for one week

of treatment protocol because it may precipitate the anteriorinnomiate dysfunction.


To asses the changes within each group after the completetreatment plan the data noted on the 1st and last day of treatmentwas used and analysed with the student’s “t” test using SPSSversion 12.0 software. The level of significance was set at p<0.01for all comparisons.

Result

From the study done to compare the effectiveness of muscleenergy technique and conventional physiotherapy in treatingthe sacroiliac dysfunction the results are significant.The averageof Oswestry Disability Index (%) relief/ decrease for Group A is27.15% and for Group B it is 19.67 %. The mean difference ±standard deviation of Oswestry Disability Index relief for GroupA and Group B are 7.49±5.709 and 7.49± 3.39.respectively. Theaverage relief in pain according to numeric pain rating scale inGroup A was 3.40 and for Group B was 2.60. The meandifference ± S.D Numeric pain rating for Group A WASO.8O±0.737 and for Group B was o.80±0.507 respectively.

Graph 1: Showing comparative differences between pain reliefgain in Group A and Group B

Graph 2: Showing comparative differences in functional abilitygained between pain relief gain in Group A and Group B

Discussion

Data from the study showed that pain and percentage ofthe disability significantly improved with muscle energytechniques and corrective exercises on abnormal anterior innominate dysfunction of sacroiliac joint. However, muscle energytechniques on sacroiliac joint dysfunction were found better interms of reduction of disability as compared to the TENS andcorrective exercises.

To data, no studies have examined the effects of TENSand corrective exercises and MET and corrective exercise onsacroiliac dysfunction. MET has been advocated as a safer andcommonly used form of manual therapy for the treatment ofsomatic dysfunction and muscle pain. Most studies haveexamined its effect in increasing range of motion although limitedresearch exists into the effect of MET on pain and increasingthe functional activities.

Noelle M. Selkow,et al 2009; In this 20 subjects with selfreported lumbopelvic pain were randomizes into two groups(MET and control ) after magnitude of pain was determined.MET of the hamstrings and iliopsoas consisted of four 5- secondhold/relax periods, while the control group received a shamtreatment. Tests for current and worst pain, and pain withprovocation were administered at baseline, immediately followingintervention and 24 hours after intervention. The visual analogscale reading for pain in MET group decreases whereas in thecontrol group the visual analog scale reading for pain increases7.In our study the abnormal anterior dysfunction of SI joint wastreated with MET for anterior dysfunction and got significantresults in treating the disability as compared to conventionalphysiotherapy.

Kanchan Rana, et al 2009; concluded that muscle energytechniques is moderately effective than G.D.Maitland conceptin treating sacroiliac joint dysfunction. Their result of the studyshowed that along with active exercises MET is moderatelysignificant over the G.D.Maitland’s technique of mobilization inimproving functional ability 9. In our study MET comes out to bemore effective in reducing disability as compared to conventionalphysiotherapy where as both the treatment were significant intreating pain.

Heinzman, KJ.,2006,Concluded the MET could be aneffective treatment in acute injuries and athletes, chronic pain,hypertonicity and muscle spasm 10 .

Pain relief in both the groups was statistically significantthat within the groups. Results after comparision between thegroups revealed significant changes in pre and post intraventionswhich indicate Group A is effective in reducing the pain whichwas measured using numeric pain rating scale and functionalactivities which was measured by using oswestry disability indexscore.

The present study was decrease in pain and disabilitysignificant with the MET and corrective exercises. Since, METis a form of manual therapy which can be mastered by trainingand practice its application at the community level which wouldbe much benefit where adequate physiotherapy andrehabilitation facility are not available. As this study is done withMET with corrective exercises and TENS with correctiveexercise, future studies on effect on other manual therapytechnique such as myofascial release, mobilization techniqueson sacroiliac joint dysfunction. The effect of the techniques canbe analysed on more objective variable such aselectromyography changes. The study can be done with largesample size with regular follow up to check the long term effectof MET.

Conclusion

The results of the study showed that both the experimentalgroup are significant in treating low back pain due to sacroiliacdysfunction but muscle energy techniques along with corrective

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exercises is moderately significant over conventionalphysiotherapy like TENS along with corrective exercise.

Referances

1. Bernard TN Jr, WI-1. Recognizing specific characteristicsof nonspecific low back pain. Chin Orthop Relat Res.1987;217:266-220.

2. Woerman AL. Evaluation and treatment of dysfunction inthe lumbar, pelvic-hip complex. In: Orthopaedic PhysicalTherapy. Donatelli and ‘Wooten, eds. Newyork: ChurchillLivingstone; 1989;403-484.

3. Sashim D. A critical analysis of the anatomy and thepathologic changes of the sacro-iliac joints. J Bone JointSurg 1930;12A: 891-910.

4. Wilson E, Payton O, Donegan-Shoaf L, Dec K. Muscleenergy technique in patients with acute low back pain: Apilot clinical trial. J Orthop Sports Phys Therapy 2003;33:502–512.

5. Daly J, Frane P, Rapoza P. Sacroiliac subluxation: acommon treatable cause of low back pain in women.Lancet 1978:496-497.

6. Leon Chaitow,Sandy Fritz, Gary Fryer “ advanced softtissue techniques on muscle energy techniques”,3 edition.

7. Noelle M. Selkow,M.Ed, ATC; Terry L.Grindstaff,; KevinM.Criss; Kelli Pugh; Jay Hertel; Susan Saliba. ‘ Short-Term Effect of Muscle Energy Technique on Pain inIndividuals with Non Specific Lumbopelvic Pain: A PilotStudy. The journal of manual and manipulative therapy2009; Vol. 17: E14-E18.

8. Karen L Barker, Christopher J Elliott,Catherine M Sackley,Jeremy CT Fairbank. ‘ Treatment of chronic back pain bysensory discrimination training, A Phase I RCT of a noveldevice ( Fair Med) vs TENS’ BMC MusculoskeletalDisorders 2008, 9:97,

9. Kanchan Rana, Nitesh Bansal, Savita. ‘Comparativeanalysis on the efficacy of the G.D Maitland’s concept ofmobilization & muscle energy technique in treatingsacroiliac joint dysfunction’. Journal of Physiotherapy andOccupational Therapy, April- June 2009; Vol.3.page no.18-22

10. Heinzman, KJ. ‘Muscle Energy Technique’ presented at2006 MN APTA spring conference, April 7-9,2006- EarlyBrown Heritage Center. Brooklyn Center,MN.

11. S. A. Anderson,G . Hanssone, Holmgre &N 0. Renberg.Evalution of The Pain Suppressive Effect of DifferentFrequencies Of Peripheral Electrical Stimulation in ChronicPain Conditions. Acta orthop. scand.1976; 47:149-157.

12. Stuesson B, Selvik G, Uden A. Movements of the sacroiliacjoints. A roentgen stereophotogrammetric analysis. Spine1989;14:162-165.

13. Albee S. The study of the anatomy and the clinicalimportance of the sacroiliac joint.JAMA 16:1273-6, 1909.

14. Paris SV. Differential diagnosis of sacroiliac joint fromlumbar spine dysfunction. In: Proc,,i;ngs of the FirstInterdisciplinary World Congress on Low Back Pain andits Relation to the Sacroiliac Joint. San Diego; 1992:212-326.

15. Cibulka M. The treatment of the sacroiliac joint componentto low back pain: a case report. Physical Therapy 1992;12:917-922.

16. Harvey J, Tanner S. Low back pain in young athletes: apractical approach Sports Med1981;6:395-406.

17. DonTigney R. Anterior dysfunction of the sacroiliac jointas a major factor in the etiology of idiopathic low backpain syndrome. Phys Therapy1990;4:250-265.

18. Lavignolle B, Vital JM, Senegas J, et al: An approach tothe functional anatomy of the sacroiliac joints in vivo.Anatomia Clinica 1983:5:169-176.

19. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rulefor classifying patients with low back pain who demonstrateshort-term improvement with spinal manipulation.Spine2002;27:2835–2843.

20. Lenehan KL, Fryer G, McLaughlin P. The effect of muscleenergy technique on gross trunk range of motion. JOsteopath Med 2003;6:13–16.

21. Laslett M, Aprill CN, McDonald B, Young SB. Diagnosisof sacroiliac joint pain: Validity of individual provocationtests and composites of tests. Man Ther 2005;10:207–218.

22. Karen L Barker, Christopher J Elliott,Catherine M Sackley,Jeremy CT Fairbank. ‘ Treatment of chronic back pain bysensory discrimination training, A Phase I RCT of a noveldevice ( Fair Med) vs TENS’ BMC MusculoskeletalDisorders 2008, 9:97

Mullai Dhinkaran / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

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Importance of Neural Biomechanics for Under Graduate Studentsof Physiotherapy – A Descriptive StudyN A Ramasubramania RajaAssoc.Professor, Gian Sagar College of Physiotherapy, Banur, Distt.Patiala-140601, Punjab

N A Ramasubramania Raja / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Introduction and Purpose of the study

The current trend for physiotherapists in manual therapyis Neural Mobilization, which is applying widely in Radiculopathypatients after neural tension tests with may not having adequateknowledge about Neural-Biomechanics and can leads totreatment less effective. The primary purpose of this study wasto describe the importance of neural-biomechanics for undergraduate students of physiotherapy.


A descriptive study was done for Physiotherapists in threemonth duration. Initially One-hundred-and-fifty-fivePhysiotherapists were responded for the questionnaire throughemail from all over India by snow ball sampling. Then thirty-fourrespondents were excluded (Therapists not consulting / treatingradiculopathy patients were excluded) and finally one-hundred-and-twenty-one respondents were selected on the basis ofinclusion and exclusion criteria.

Results

After taken the percentages of respondents from thequestionnaire, Chi Square test was performed in various focusesto find out the relationship between them. There was a highlysignificant relationship between the experience of the therapistsand the level of knowledge about neural-biomechanics, ÷2 =107.58 with d.f-3, (P<0.001) and a significant relationshipbetween the reasons for not assessing the neural tension testsand complications of neural tension tests, ÷2 = 43.1 with d.f-1,(P<0.001)

Conclusion

The Neural-Biomechanics was not included inPhysiotherapy curriculum of under graduates in all over India.This may be the important reason for less effective of neuralmobilization and also the cause for complications of NeuralTension tests in Radiculopathy Patients. All the respondents ofthis study were given suggestion to give more importance toinclude as a separate chapter of Neural-Biomechanics inBiomechanics of Under-graduate curriculum.

Key Words

Neural-Biomechanics, Neural Tension Tests, Neural-Mobilization, Under-Graduate Curriculum.

Introduction

When the therapist deals with the radiculopathy patients,he/she may have to assess neural tension tests, and may haveto apply neural mobilization for the same is the current trend.We are applying the joint mobilization in various conditions alongwith the knowledge of structure and function of that mobilizingjoint. This may be the important reason for successful in outcomeof Joint mobilization.

The Neural Biomechanics is the basic for Neural Tensiontests and Neural Mobilization. So if the therapist assessing neuraltension tests and applying neural mobilization with the knowledgeof neural biomechanics that may more effective in the clinicalaspects.

Mark T. Walsh PT, MS, CHT, ATC (2005), the use of upperlimb neural tension testing (ULNTT) and neural mobilization byphysical and occupational therapists has become common inclinical practice. There is sufficient biomechanical evidence thatthe peripheral nerve under tension undergoes strain and glideswithin its interfacing tissue. Evidence supports that ULNTTcauses strain within the peripheral nervous system however; itis also evident that ULNTT places strain on other multi-segmentaltissues. There is limited evidence reporting favorable outcomeswhen using neural mobilization to treat specific patientpopulations, and the appropriate parameters of dosage (i.e.,duration, frequency, and amplitude) remain to be confirmed.Clinical application of these techniques must be applied in apractical manner that relies on continual clinical reasoning. Theclinician should integrate basic science and experimentalevidence as we work to achieve a sufficient level of confidencein the development of evidence-based practice.

Problem of the Study

• Whether the neural biomechanics is included in the undergraduate curriculum of physiotherapy or not.

• Whether the therapists are assessing the neural tensiontests and applying the neural biomechanics with theknowledge of Neural Biomechanics or not.

• Whether it is important to include a topic of NeuralBiomechanics in the under graduate curriculum ofPhysiotherapy or not.

Statement of the Study

Importance of Neural-Biomechanics for under graduatestudents of Physiotherapy.

Aims and Objectives

• To find out the importance of Neural-Biomechanics for undergraduate students of Physiotherapy.

Significance of the Study

• Improve the clinical skills of therapists to assess the NeuralTension Tests and to apply the neural mobilization.

• To include a separate chapter as a “Neural Bio-Mechanics”in the curriculum of under graduate students ofPhysiotherapy.

Literature Review

Mark T. Walsh PT, (2005) The clinician should integratebasic science and experimental evidence as we work to achievea sufficient level of confidence in the development of evidence-based practice.19

Kathleen l. Devine, (1984) stated the “Physical Therapistsmust be competent in applying biomechanics to a variety ofsituations”1

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Rebecca l. Craik, (1984) stated that “Neural Biomechanicscan provide sensitive measures of motor performance”2

David S. Butler, (1989) stated that Adverse Neural Tensionis excessive nerve tightness or sticking, which can be causedby disc bulge, spine changes, or scar tissue.15

McLellan DL, Swash M (1976), suggested that, wherelongitudinal movement of a peripheral nerve is restricted,continual trauma results from normal movements of the limb.17

Coppieters MW, Stappaerts KH, Everaert DG, Staes FF.(2001) Stated that If the nerve bedding is elongated throughoutits whole length, the available ROM is markedly reduced andsensory responses can be elicited throughout the entire arm.18

Research Methodology

Nature of Study

This was a descriptive Study on an importance of Neural-Biomechanics for under graduate students of Physiotherapy.The primary data were collected from the therapists with help ofquestionnaires through e-mail. The secondary data werecollected through the electronic databases (APTA, AustralianPhysiotherapy Association, PubMed, search engines, etc.)

Ethical Consent

Consent was taken from all the subjects through the emailprior to this study.

Study Approach

Survey Method.

Study Tool

Structured Questionnaire.

Study Location

Gian Sagar College of Physiotherapy, Banur, Distt.Patiala.

Sampling Methodology

Snow ball sampling was used by sending the questionnaireto Three hundred and seventy six Physiotherapists withrequested to forward the same to other therapists. Then onehundred and fifty five therapists were responded for thatquestionnaire through email from all over India and finally onehundred and twenty one respondents were selected on the basisof Inclusion and Exclusion criteria.

Sampling Criteria

Inclusion Criteria

• Physiotherapists who were completed their under graduatesfrom the Indian Universities

• Physiotherapists consulting and treating the Radiculopathypatients

• Both male and female therapists were taken as subjects

Exclusion Criteria

• Physiotherapists who were not treating the Radiculopathypatients were excluded.

Contact Method

Through email: A follow-up to the original mailing was donewith a reminder mail, which was sent to those who did notrespond by the deadline noted on the questionnaire.

Types of Question

To collect accurate data from the respondent and also tomake them convenient, questions have been framed by usingdifferent type of questionnaire like multiple choice questions,dichotomous and open ended. The questionnaire was designedto focus on the following points:1. Experience2. Institutions from where they have completed their under

graduation3. Consulting, treating and numbers of radiculopathy patients4. Knowledge and source of knowledge gained about neural

biomechanics.5. Applications and outcome of Neural tension tests and neural

mobilization6. Importance of Neural Biomechanics.

Analysis of the study

By Using Chi Square test

Analysis No.1

To find out the clinical experience of the respondents hasany relation on the level of knowledge.

Table value @ p 0.001 Significance and d. o. f of 3 = 16.27,which is lesser than the calculated value 30.605, Therefore,There is significant relationship among the experience of thetherapists and level of knowledge about neural biomechanics.

Analysis No.2

To find out the Level of Knowledge about neuralbiomechanics of the respondents has any relation on how theknowledge gained about neural

Table value @ p 0.001 Significance and d. o. f of 3 = 16.27,which is lesser than the calculated value 107.58, Therefore,There is significant relationship among the level of knowledgeabout neural biomechanics and how the knowledge gained aboutneural biomechanics.

Analysis No. 3

To find out the Knowledge from where gained about neuralbiomechanics of the respondents has any relation on outcomeafter neural mobilization.

Table value @ 5% Significance and d. o. f of 6 = 12.59,which is greater than the calculated value 6.85. Therefore, thereis no significant relationship among the knowledge from wheregained about neural biomechanics and outcome after neuralbiomechanics.

Analysis No. 4

To find out the Level of Knowledge about neuralbiomechanics of the respondents has any relation on Applicationof neural mobilization

Table value @ p 0.001 Significance and d. o. f of 2 = 13.82,which is lesser than the calculated value 53.90, Therefore, Thereis significant relationship among the level of knowledge aboutneural biomechanics and application of neural biomechanics.


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Data Analysis And Interpretation

Experience after under graduationS.No Options No. of Respondents %

1 <1 year 10 8.32 1-2 years 26 21.63 2-5 years 52 42.84 >5 Years 33 27.3Level of Knowledge about Neural Mobilization1 Excellent 0 02 Good 19 15.73 Average 102 84.34 None 0 0Knowledge from where gained about Neural Biomechanics1 During under graduate from your teacher 6 52 During under graduate by your self reference 12 103 By additional short duration course 17 144 By CME/Journal after under graduation 86 71Reasons for not applying neural mobilization1 Not necessary for that patient 51 42.12 Not having practical knowledge about it 64 52.93 Not aware about neural mobilization 6 54 Contraindication 0 0Segment mobilizing in Radial nerve mobilization1 Oscillation of segment 62 51.22 Head rotation to the opposite side 21 17.43 According to irritability 28 23.14 Not aware about neural Mobilization 10 8.3Outcome after neural mobilization1 More effective 95 78.52 Less effective 17 14.13 No effective 0 04 Not aware 9 7.4Complications of neural mobilization1 Never get complicated 61 50.42 Rarely complicated 51 42.23 Mostly complicated 0 04 Not applying 9 7.4

Analysis No. 5

To find out the Reason for not assessing neural tensiontests has any relation on complications of neural tension tests

Table value @ p 0.001 Significance and d. o. f of 1 = 10.83,which is lesser than the calculated value 43.10, Therefore, thereis significant relationship among the reason for not assessingthe neural tension tests and complications of neural tension tests.

Analysis No. 6

To find out the Reason for not applying neural mobilizationhas any relation on complications of neural mobilization

Table value @ p 0.001significance and d. o. f of 4 = 18.47,which is lesser than the calculated value 98.23, Therefore, Thereis significant relationship among the reason for not applyingneural mobilization and complications of neural mobilization.

Analysis No. 7

To find out the segment mobilizing in radial nervemobilization has any relation on complications of neuralmobilization.

Table value @ p 0.001significance and d. o. f of 3 = 16.27,which is lesser than the calculated value 107.77, Therefore,There is significant relationship among the segment mobilizingin radial nerve mobilization and complications of neuralmobilization.


Summary and Findings

• The respondents are in different age groups and most ofthe respondents (49%) are between 26 – 30 years of age.20% of the respondents are above 30 years and rest 31%are below 25 years.

• The gender of the respondents is approximately equal.• The respondents are done their under graduation from

twelve various universities in India and most of the (53.7%)respondents are completed their under graduation from TheTN Dr. M.G.R Medical University, Chennai.

• The most (84.3%) of the therapists are having only averageknowledge about the Neural-Biomechanics.

• Approximately 50% of the respondents with more than 5years experience having good knowledge about neuralbiomechanics.

• The most (71%) of the therapists are gained the knowledgeabout neural biomechanics by CME /Conference after theunder graduation period and next to that the majority (14%)of the therapists gained by additional course.

• Among 15.7% of the respondents having good knowledgeabout neural biomechanics, 90% of the respondents aregained by additional course after under graduation, rest5% by the teacher during under graduation and 5% by CME.

• Among 71% of the respondents having average knowledgeabout neural biomechanics, 85% of the respondents aregained by CME or conference after under graduation, 11%gained by self reference during their under graduation and4% gained by the teacher during under graduation.

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• 90% of the respondents having with good knowledge aboutneural biomechanics applying neural mobilization for allthe patients.

• 70% of the respondents having with average knowledgeabout neural biomechanics applying neural mobilization forfew patients.

• 100% of the respondents are given the statement that thetopic of Neural-Biomechanics was not included in theircurriculum of under graduation.

• 100% of the respondents with good knowledge on neuralbiomechanics are given statement as more effective inoutcome of neural mobilization.

• 100% of the respondents those who gained the knowledgeabout neural biomechanics by additional course, givenstatement as more effective of neural mobilization inoutcome.

• 75% of the respondents those who gained the knowledgeof neural biomechanics by CME or conference, givenstatement as more effective of neural mobilization inoutcome.

• 100% of the respondents are given suggestion to give moreimportance of neural biomechanics for under graduatestudents as it may improve the skills to assess neuraltension tests and to apply neural mobilization.

• 70% of the respondents those who are not assessing theneural tension tests as they are not having soundknowledge about it, getting complications in rarely duringtension tests.

• 65% of not having practical knowledge about neuralmobilization, getting complications rarely after neuralmobilization.

• 50% of the respondents of oscillating the segment whileradial nerve mobilization getting complications rarely.

• Rarely complications after radial nerve mobilization by 75%of the respondents of head rotation to mobilize.

• Never get complications after neural mobilization by 92%of the respondents of mobilizing the segment according tothe irritability of the nervous tissue.


√ Sampling size is not equal in all the regions of India.√ Interview is done through only by email√ Level of Knowledge about neural biomechanics is not

assessed by objective in detail.√ Only Cervical and Lumbar Radiculopathy patients were

considered for analysis√ Only important special tests were asked in the

questionnaire.√ Outcome of the patients after neural mobilization is not

analyzed in detail√ Complications of neural mobilization are not analyzed in

detail.

Conclusion

√ There is significant relationship among the level ofknowledge about neural biomechanics and how theknowledge gained about neural biomechanics.

√ There is significant relationship among the level ofknowledge about neural biomechanics and application ofneural mobilization

√ There is significant relationship among the reason for notapplying neural mobilization and complications of neuralmobilization.

√ This study shows that Neural-Biomechanics was notincluded in Physiotherapy curriculum of under graduatesin all over India.

√ This may be the important reason for less effective of neuralmobilization and also the cause for complications of NeuralTension tests and neural mobilization in RadiculopathyPatients.

√ 100% of the respondents of this study were givensuggestion to give more importance to include as a separatechapter of Neural-Biomechanics in Biomechanics of Under-graduate curriculum.

References

1. Kathleen l. Devine “Competencies in Biomechanics forthe Physical Therapist - Suggestion for Entry-LevelCurricula” Physical TherapyVolume 64 / Number 12,December 1984, 1883-1884

2. Rebecca l. Craik, (1984)”Biomechanics A Neural ControlPerspective” Physical Therapy, Volume 64 / Number 12,December 1984, 1810-1811.

3. Butler, D. S., Shacklock, M. O., & Slater, H. (1994).Treatment of altered nervous system mechanics. In J. D.Boyling & N. Palastanga (Eds.), Grieve’s modern manualtherapy, the vertebral column (2nd ed., pp.693-703).Edinburgh: Churchill Livingstone.

4. Ekstrom, R. A., & Holden, K. (2002). Examination of andintervention for a patient with chronic lateral elbow painwith signs of nerve entrapment. Physical Therapy, 82, 1077-1086.

5. Elvey, R. L. (1994). The investigation of arm pain: signs ofadverse responses to the physical examination of thebrachial plexus and related tissues.

6. In J. D. Boyling & N. Palastanga (Eds.), Grieve’s modernmanual therapy, the vertebral column (2nd ed., pp.577-585).Edinburgh: Churchill Livingstone.

7. Kleinrensink, G.J., Stoeckart, R., Mulder, P. G., Hoek, G.,Broek, T., Vleeming, A., & Snijders, C. J. (2000). Upperlimb tension test as tools in the diagnosis of nerve andplexus lesions. Anatomical and biomechanical aspects[Abstract]. Clinical Biomechanics, 15 (1), 9-14. RetrievedFebruary 25, 2003 from OVID database.

8. Rydevik, B., Lundborg, G., & Skalak, R. (1989).Biomechanics of peripheral nerves. In M. Nordin & V. H.Frankel (Eds.), Basic biomechanics of the musculoskeletalsystem (2nd ed., pp.75-87).

9. Malvern, PA: Lea & Febiger. Shacklock, M. (1995).Clinicalapplication of neurodynamics. In M. Shacklock (Eds.),Moving in on pain (pp.123-131). Sydney: Butterworth-Heinemann.

10. Shacklock, M. O., Butler, D. S., & Slater, H. (1994). Thedynamic central nervous system: structure and clinicalneurobiomechanics. In J. D. Boyling & N. Palastanga (Eds.),Grieve’s modern manual therapy, the vertebral column (2nded., pp.21-38). Edinburgh: Churchill Livingstone.

11. Butler D, Gifford L. The concept of adverse mechanicaltension in nervous system. Part 1: Testing for dural tension.Physiother. 1989;75:623–636.

12. McLellan DL, Swash M. Longitudinal sliding of the mediannerve during movements of the upper limb. J NeurolNeurosurg Psychiatry. 1976;39:566–570.

13. Coppieters MW, Stappaerts KH, Everaert DG, Staes FF.Addition of test components during neurodynamic testing:Effect on range of motion and sensory responses. J OrthopSports Phys Ther. 2001;31:226–237.

14. Mark T. Walsh PT, MS, CHT, ATC Hand & OrthopedicPhysical Therapy Associates, Levittown, Pennsylvania,Journal of Hand Therapy Volume 18, Issue 2, April-June2005, Pages 241-258

15. Hines T, Noakes R, Manners B. The upper limb tensiontest: Inter-tester reliability for assessing the onset of passiveresistance R1. J Man Manip Ther. 1993;1:95–98.


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Comparing the Effectiveness of Lumbar Stabilization Exerciseswith General Spinal Exercises in Patients with Postero-lateral DiscHerniationsMuhammad Naveed Babur1, Danyal Ahmed2, Farah Rashid3

1Isra School of Rehabilitation Sciences, Isra University, Islamabad Campus, 2National Hospital, Lahore, 3Shifa College of Medicine,Islamabad, Pakistan

Muhammad Naveed Babur / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Objective

To compare the effectiveness of lumbar stabilizationexercises (LSE) with general spinal exercises (GSE) in patientswith postero lateral disc herniations.

Methods

The randomized controlled trial was conducted A sampleof 50 patients was taken from February 2010 to April 2010; andthey were randomly placed either in control or experimentalgroup, 25 patients in each group. The sample was exclusivelytaken from the Physiotherapy Department of National Hospitaland Medical Center DHA Lahore.

Results

The progress of all the patients was measured on a unifiedscale describing 5 disability variables, pain intensity, walking,standing, sleeping and social activity according to modifiedOswestry Scale. All participants performed their particulartherapeutic exercise with their regular sessions of physicaltherapy for 4 weeks. By summing up the total of 5 variables, atotal pre-exercise and post exercise score were obtained. Thistotal disability score of the two groups were analyzed statisticallyand t- test was applied which shows statistically significant resultswith p = 0.000007.

Conclusion

Hence patients who performed LSE protocols improvedsignificantly better with lower disability scores compared withpatients who had GSE protocols.

Key Words

Lumber stabilization exercises (LSE), General spinalexercises (GSE), chronic lower back pain (CLBP), prolapsedintervertebral disc (PIVD).

Introduction

“Lumbar stabilization exercises” is a modern concept inthe management of patients with poster-o-lateral disc herniation.Unfortunately this method of treatment is not routinely in practicein clinical settings. Substantial work in this area is needed toestablish significance of this method. Current research hasreported that in most cases of low back pain(LBP) due to discherniations, certain muscles of the back that stabilize the spineare reflexively inhibited after injury. Interestingly patients get backto their normal daily activities without having their musclescompletely healed. These specific muscles work together tosupport and stabilize the spine to help prevent LBP. Thesemuscles include the lumbar multifidi and the transversusabdominus: The lumbar multifidi are the deepest layer of musclesof the back. They attach from the vertebral arches to the spinous

processes. Each multifidi connects 1-3 vertebrae, controllingmovement between the vertebrae.

The lumbar “stabilization exercises” is a program of backmuscles exercises designed to aware patients how to improvestrengthening and enhance flexibility in a pain-free range. It notonly improves the patient’s physical condition and symptomsbut also helps the patient to have efficient movement. It providesthe patient with movement awareness, knowledge of safepostures, functional strength and coordination that promotesmanagement of LBP.1

Patients undergoing conservative management of theirhernations are routinely treated by physical therapists. Theirregular physical therapy sessions include heat, ultrasound,manual therapy, postural care advice and therapeutic exercises.The conventional therapeutic exercises are either William’sflexion or Mackenzi’s extension.Combination of both is alsorecommended by many. To some extent patients are benefitedby these exercises protocols and they become pain free verysoon. But majority of the back pain patients especially due tohernation have to suffer a lot due to their weak muscles ofextensor compartment and peak intensity of pain now and thenin the following years. 2

The purpose of the study is that the addition of these lumbarstabilization exercises will really benefit these patients and canprovide them with permanent relief. Once the core stabilitymuscles are activated the overall spinal proprioception isimproved and the patients are more functionally independent,gain additional muscular strength and are free of pain.

Subject and Methods

Randomized controlled single blind trial, only the researcherknows whether participants are in control or experimental group.Participants of the study are of both gender and any age havingestablished diagnosis of postero lateral disc herniations. Theyare divided in two groups control and experimental. Control grouphad general spinal exercises and experimental group lumbarstabilization exercises with their regular physical therapysessions consisting of heat, ultrasound and manual therapy.Participants were assigned their groups randomly.

The study was conducted at Physical Therapy ClinicNational Hospital and Medical Center DHA Lahore, It took abouttwo months to collect clinical data and analyze it for conclusionfrom the participants of the study. For continuous 4 weeksparticipants were taught and practiced either GSE of LSE withtheir regular sessions of physical therapy. Through simplerandom technique 50 patients were selected.

Experimental group received the LSE protocols whereascontrol group received conventional therapeutic exercises withtheir regular sessions of physical therapy. The progress of thepatients will be measured on modified Oswestry scale.

As this study is based on the subjective evaluation of thepatients in their activities of daily life so modified Oswestry scaleis the only instrument otherwise no else instruments has beenused.

Case record form for each patient having regular physicaltherapy sessions was maintained. And their progress was notedon this. Choice of the therapeutic exercise was the only differencebetween two groups.

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The modified Oswestry Scale , which was used in the studyas an assessment tool.

Modified Oswestry Scale

Pain Intensity

1. I have no pain at the moment2. The pain is very mild at the moment3. The pain is moderate at the moment4. The pain is fairly severe at the moment5. The pain is very severe at the moment6. The pain is the worst imaginable at the moment

Walking

1. Pain does not prevent me walking any distance2. Pain prevents me from walking more than 2 kilometres3. Pain prevents me from walking more than 1 kilometre4. Pain prevents me from walking more than 500 metres5. I can only walk using a stick or crutches6. I am in bed most of the time

Standing

1. I can stand as long as I want without extra pain2. I can stand as long as I want but it gives me extra pain3. Pain prevents me from standing for more than 1 hour4. Pain prevents me from standing for more than 30 minutes5. Pain prevents me from standing for more than 10 minutes6. Pain prevents me from standing at all

Sleeping

1. My sleep is never disturbed by pain2. My sleep is occasionally disturbed by pain3. Because of pain I have less than 6 hours sleep4. Because of pain I have less than 4 hours sleep5. Because of pain I have less than 2 hours sleep6. Pain prevents me from sleeping at all

Social Activity

1. My social life is normal and gives me no extra pain2. My social life is normal but increases the degree of pain3. Pain has no significant effect on my social life apart from

limiting my more energetic interests e.g. sport4. Pain has restricted my social life and I do not go out as

often5. Pain has restricted my social life to my home6. I have no social life because of pain

The progress of the patient was measured subjectively onthis modified scale pre test and post test. All the participantswere asked to fill this form before and after end of the exercisetrial.

The lower the total disability score which is the aggregateof all 5 variable the greater is the improvement of the patient inhis activities of daily living.

Results

To check the difference between means of the total disabilityscore of the two groups, student t test as it is the most appropriatetest for this type of analysis , was applied in SPSS. Theconfidence interval was set to be at 95% with 48 degree offreedom. The resultant P value came out to be 0.000007 whichis less than 0.05 (statistically significant) showing that thedifference between means does exist. Table 1 and figure 1corresponds to the total disability score at the start of the study.

Figure 2 shows post test total disability score in experimentalgroup and, figure 3 is the post test total disability score in controlgroup. Total disability post-test scores were lower in experimentalgroup than control which indicates that LSE group recoveredmore efficiently and reached functional independency more ascompared to general spinal exercises group.


Fig. 1: Total disability score in all participants at start of the trial.

Fig. 2: Total disability score experimental group after trial.

Fig. 3: Control group total disability score after trial.

Discussions

Result of the study depicts effectiveness of lumbarstabilization group over general spinal exercise group. Obviouslydesigning a general plan for all back pain patients is routine inour clinics insufficient to meet the demands of diverse group ofback complain patients. Especially lumbar disogenic patientsfeel really bad pain and disability after having prolapse. TheseLSE protocols specifically focus on the core stability musculatureof the spine so that lumbar spinal muscles are actively engagedin exercise; hence these start building up and are notreflexogenically inhibited. By this mechanism spine is able tocontrol disc contents even with dynamic postures. These resultsare consistent with the study of Yilmaz F; Yilmaz A; Merdol F;

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Parlar D; Sahin F; Kuran B. They showed that the dynamiclumbar stabilization exercises are an efficient and usefultechnique in the rehabilitation of patients who have undergonemicrodiscectomy. These relieve pain, improve functionalparameters and strengthen trunk and back extensors.7 Althoughthe diagnosis in their study was concerned primarily with postoperative rehabilitation but the underlying cause is the disc, themuscle work is same and biomechanics to support the disc isalso same.

On the other hand GSE are mainly flexibility exercises andstudy showed that benefits of these are not better, these oldfashioned exercise do not have potential to actively engagelumbar spinal muscles so these are able to control spine indifferent postures. The beauty of these exercises is that theseare typically done in various different positions, in prone, supine,kneeling, half kneeling so these train the spinal musculature toadapt itself to various activities of daily life. Much new informationwas also gathered to show that most of patients were obeseand in the 4th decade of life and in Pakistan sedentary life styleis mainly responsible for this. Women suddenly gain weight aftermenopause that is also a contributory factor.

Except when patient is in acute condition, these exercisesare perfectly safe, comfortable and easy to learn for all patients.This finding was consistent with all participants in experimentalgroup. Regarding safety and efficacy another study hasconcluded these primarily benefits by Liebenson C; Hyman J;Gluck N; Murphy DR.5 in their study on spinal stabilization. Thisstudy also proved that Spinal stabilization exercises are safeand have demonstrated effectiveness in patient with low backpain including those with nerve root compression. Spinalstabilization is a low technology rehabilitation approach to spinalrehabilitation that has been shown to outperform passive therapyand higher technology rehabilitation conditioning programs.

So it is an established fact that these exercises of lumbarstabilization does not have any contraindications and can readilybe included in any therapeutic exercise program.

But many important facts are also disclosed at the end ofthe study like many patients fell bored when told to exercise.They took these exercises very light nonetheless their progresswas satisfactory. This proves therapeutic efficacy and potentialof stabilization exercises to activate the core stability effects.

Hydrotherapy is largely being advocated in Pakistan forpatient with CLBP due to disc and their effects are very excellentbut not every patient has the affordability of a swimming poolbut LSE are very easy to do, hence these strongly suggeststheir cost effectiveness and convenience. In future a clinical trialcan be conducted in discogenic patients to compare their postexercise pain disability score in pool and at home utilizing LSEprotocols. This will further yield useful facts.

Besides therapeutic efficacy of these exercises it is alsovery mandatory for all working therapist to be fluent and accuratewith their techniques in such patients. The researcher used manytechniques described by Freddy M. Kaltenborne and found thesehaving excellent results. Obviously if the mechanical problem

is not be addressed and resolved patient will tend to go inchronicity of back pain. Regarding management of such patients;choice of therapeutic exercise is selected in trial but in futurerole of modalities and manipulative management can also beclinically established. Progress of patients can vastly differ whowill receive different techniques in manual therapy and differentmodalities in physical therapy. So, new horizons are open forfuture researchers, to conclude further useful evidence incrippling condition of disc herniation.

Conclusion

The result of the statistical analysis concludes that thelumbar stabilization exercises are of better choice whencompared with general spinal exercises in patients with posterolateral disc herniations. The result is statistically significant witht value (0.000007) much less than 0.05. The study also supportsthe facts that these stabilization exercises are better option,therapeutically safe and easy to perform. The findings of thestudy suggest that “lumbar stabilization exercises” should beincorporated with treatment plan of patients having poster-o-lateral discogenic pain syndromes.

References

1. Carolyn Kisner, Lynn Allen Colby, Therapeutic exercises5th edition, Jaypee Punlishers 2007.

2. Adams MA, May S, Freeman BJ, Morrison HP, Dolan P.Effects of backward bending on lumbar intervertebral discs.Relevance to physical therapy treatments for low back pain.Spine 2000 Feb 15;25(4):431-7.

3. INTERNATIONAL JOURNAL OF REHABILITATIONRESEARCH, Dec 1, 2004; 27(4): 297-301 (AMED).

4. JOURNAL OF BODYWORK AND MOVEMENTTHERAPIES, Oct 1, 1999; 3(4): 208-14 (AMED).

5. TOPICS IN CLINICAL CHIROPRACTIC, Sep 1, 1996; 3(3):60-74 9147951 (AMED).

6. JOURNAL OF SPORTS CHIROPRACTIC ANDREHABILITATION, Jun 1, 1998; 12(2): 55-64 (AMED).

7. J REHABIL MED, Jul 1, 2003; 35(4): 163-7 (AMED)0053785

8. Journal Of Korean Academy Of Nursing [J Korean AcadNurs] 2008 Dec; Vol. 38 (6), pp. 902-13. (MEDLINE).

9. Archives of Physical Medicine and Rehabilitation (ArchPhysMedRehabil) 2007 Dec; Vol.88 (12),pp.1734-6.(MEDLINE).

10. Archives of Physical Medicine And Rehabilitation[ArchPhysMedRehabil] 2007Dec; Vol.88(12),pp.1734-6.(SPORTDiscuss).

11. Athletic Therapy Today(ATHLETICTHERTODAY),2008Jul;13 (4):34-6 (13ref)(CINAHL)


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Comparsion of Efficacy Between Simple and ComplexPlyometrics Training on Concentric Hamstring Torque, AngularVelocity and Power using Isoinertial DynamometerN P SinghReader, Jammu College of Physiotherapy, Jammu

N P Singh / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Introduction

One of the primary goal of any rehabilitation programis to return muscular strength to pre injury level. Thedevelopment of muscular strength is also an essentialcomponent of any conditioning program prentice.2

Strength is the ability of muscle to develop peak force ortorque during a maximal voluntary contraction under a givenset of conditions sale.1 Strength in relation to sports activity hasbeen discussed and authors have stated that stronger athletesare better performers and have fewer injuries. Studies haveindicated that stronger muscles provide better protection ofarticulation if the line of application of resulted muscular tensionis in integrity with the joint.

In sports training and rehabilitation of athletic injuries, theconcept of specificity has emerged as an important parameter.Peak power in sports require technical skill and power and isdependent upon the speed at which muscular force can begenerated. The form of training that combines speed ofmovement with strength is plyometrics. Normal physiologicalmovement rarely begins from static starting position but ratheris preceded by an eccentric pre stretch that loads the muscleand prepares it for the ensuring concentric contraction. Thiscycling of eccentric-concentric contraction is known as stretchshorten cycle prentice.2 Plyometrics take advantage of elasticityof muscles and the stretch reflex Bosco.3 This stretch reflexmechanism is one by which force is produced during stretchshortening cycle. The mechanoreceptors that are responsiblefor stretch reflex are muscle spindles and golgitendon organlundon.4 The stretch shortening cycle involves storing potentialenergy in a stretched muscle. Stretch shortening cycle involvesthree phases, eccentric phase where stretching of muscle occurswhich stimulates muscle spindle that ultimately causes muscleto contract. Amortization phase which refers to time periodbetween eccentric and concentric contraction, longer theAmortization phase greater the loss of stored energy. Concentricphase where stored energy combined with voluntary contractioncontribute to provide force necessary for subsequent movementor jump Mathew.5 Though the plyometrics training has gainedpopularity as a method to heighten the excitability of the nervoussystem for improved reactive ability of neuro muscular system.The complex plyometric training is gaining popularity as atraining strategy combining weight training and polymeric trainingfor improving muscular power and athletic performance.6

William7 Participation in combined program of polymeric andweight training improves strength and power.

Strength ratios of power , torque and angular velocity onquadriceps among players of different sports have been studiedearlier. No such report is available for hamstrings torque,angular velocity and power in normal individuals . Thereforethis study was undertaken to determine the efficacy of trainingon hamstrings torque, angular velocity and power betweensimple and complex polymeric training.


An experimental study with different subject design wasconducted. A group of 20 young healthy active collage goingmale students were taken for this study , with mean age of (23.4±2.11) , mean height (170.8± 5.61) and mean weight of ( 66.64 ±

7.23) . The selection was done on random basis. The samplewas then randomly divided into two equal groups A (simpleplyometrics) and group B (complex plyometrics).

Any recent or preivous injury to lower limb or subject unableto perform 5 squats on continuity and unable to complete singleleg stance for 30 sec or lack of flexibility among muscles oflower limb formed an exclusion criteria in selecting the subject.

A pneumatic resistance based ‘ HUR’ isoinertialdynamometer was used for testing purpose . Prior to testingsubjects underwent 5 min warm up and Knee flexion exercisewith mild resistance followed by mild hamstrings stretching.Torque, Angular velocity and power for each subject wasmeasured using HUR Dynamometer. Group A (Simpleplyometrics) subjects were made to perform box jumps for 4weeks with intensity of 4 times a week in 3 set of 10 repetitonswith 1 min rest interval between the sets.

Group B (Complex plyometrics) was put on training of boxjumps having same criteria as for simple plyometrics,but soonafter box jumps, the subjects were made to perform resistedhamstring curls with 5 kgs sand bag in 3 sets of 10 repetitionseach with 30 sec rest interval between the sets performed tohave maximum gain in strength.

After 4 weeks of training protocol the subjects were againtested for hamstrings torque, angular velocity and power usingHUR extension/curl dynamometer using same testing protocolas used earlier before 4 weeks training. Related ‘t’ test was usedfor intragroup comparision for simple and complex traininggroups and unrelated ‘t’ test was used for intergroup comparisionbetween simple and complex training groups.

Results

Intragroup comparision for group A (simple plyometrics) didnot show any statistically significant differences for hamstringstorque, angular velocity and power at pressure 2 bars and 4bars after simple plyometrics training for 4 weeks with p-value >.05. However there is statically insignificant increase in powerof about 37% for right side hamstrings at 2 bars and 13% forright hamstrings at 4 bars. Similarly there is 21% increase in 2bars and 12.8% in left hamstrings at pressure 4 bars.

Similarly the intragroup comparison for group B ( complexplyometrics) did not show any statistically significant differencesfor hamstrings torque , angular velocity and power at pressure2 bars and 4 bars after complex plyometric training for 4 weekswith p- value > .05.

However the results show statistically insignificant increasein power of about 50.3% for right hamstrings at 2 bars and 30.8%for right hamstrings at 4 bars . Similarly left hamstrings at 2 barsshow increase in power of about 27.6% where as for lefthamstrings at 4 bars there is increase of about 22.5%.

While doing the intergroup comparison between simple andcomplex plyometrics groups no statistically significant resultswere noted for torque , angular velocity and power for right andleft side hamstrings at pressure 2 bars and 4 bars.

Discussion

The results of the study show statistically insignificantincrease in power of about 37% for right side hamstring at 2bars and 13% for right hamstrings at 4 bars. Similarly, there is

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Angular Velocity (d/sec)

Before Training After TrainingSide and Pressure t- value Remarks

Mean(d/sec) S.D. Mean(d/sec) S.D.RT HAMS AT 2 BAR 163.9 73.575 186.29 60.75 0.742 NSRT HAMS AT 4 BAR 162.9 52.407 193.48 39.152 1.477 NSLT HAMS AT 2 BAR 152.16 71.673 173.36 76.079 0.641 NSLT HAMS AT 4 BAR 162.57 65.601 181.38 59.970 0.182 NS

Torque (nm)

Before Training After TrainingSide and Pressure t- value Remarks

Mean (nm) S.D. Mean(nm) S.D.RT HAMS AT 2 BAR 11.5 4.95 13.61 4.96 .952 NSRT HAMS AT 4 BAR 27.8 9.15 27.80 5.75 .000 NSLT HAMS AT 2 BAR 9.60 4.94 9.50 4.60 .047 NSLT HAMS AT 4 BAR 30.70 5.20 27.90 6.35 1.078 NS

Power (w)

Before training After trainingSide and Pressure t-Value Remarks %age

Mean (w) S.D. Mean (w) S.D. increaseRT HAMS AT 2 BAR 39.40 24.432 54.02 23.8 .353 NS 37%RT HAMS AT 4 BAR 97.85 40.47 111.79 37.143 .802 NS 13%LT HAMS AT 2 BAR 30.81 25.415 37.58 25.87 .590 NS 21%LT HAMS AT 4 BAR 78.95 32.02 89.13 31.499 .717 NS 12.8%

Torque (nm)

Before training After trainingSide and Pressure t-value Remarks

Mean (nm) S.D. Mean (nm) S.D.RT HAMS AT 2 BAR 9.50 3.13 11.20 4.05 1.050 NSRT HAMS AT 4 BAR 29.50 5.82 29.40 3.50 .093 NSLT HAMS AT 2 BAR 9.2 4.9 11 4.73 .830 NSLT HAMS AT 4 BAR 29.40 2.71 28.4 4.06 .647 NS

Angular Velocity (d/sec)

Before training After trainingSide and Pressure t-value Remarks

Mean (d/sec) S.D. Mean (d/sec) S.D.RT HAMS AT 2 BAR 160.11 72.6 194.5 51.05 1.225 NSRT HAMS AT 4 BAR 155.7 58.4 206.2 59.230 1.992 NSLT HAMS AT 2 BAR 103.91 64.3 138.24 36.109 1.471 NSLT HAMS AT 4 BAR 146.2 50.05 173.1 40.2 1.324 NS

Before Training After TrainingSide and Pressure t-value Remarks %age

Mean (w) S.D. Mean (w) S.D. increaseRT HAMS AT 2 BAR 28.6 26.01 43 27.3 1.207 NS 50.3%RT HAMS AT 4 BAR 85.9 41.26 112.3 52.103 1.259 NS 30.8%LT HAMS AT 2 BAR 39.25 60.5 29.41 20.9 0.486 NS 27.6%LT HAMS AT 4 BAR 76.5 31.3 93.7 30.5 1.247 NS 22.5%

Power (w)

21% increase in power for left hamstrings at pressure 2 barsand 12.8% in left hamstrings at pressure 4 bars which is inaccordance with the study of Hewett et al. (1996) who statedthat plyometrics jump training has been shown to safely andeffectively improve lower limb strength and power in young highschool aged women.8

However, hamstrings did not show any statisticallysignificant differences before and after simple plyometrics atresistance 2 bars and 4 bars after 4 weeks training which is indisagreement with the study of Lubbers et al. (2003) who foundthat anaerobic power improved significantly after 4 weeksplyometrics training.9


The reason for these insignificant results can beattributed to the fact that the time period for training was less,which is not in accordance with previous studies which havereported improvement in both peak power and vertical jump inall training groups after 8 weeks of plyometrics exercise (Williamet al. 1996).10 Leah et al. (2004)11 suggested that performanceindicators of Power, Torque and Angular Velocity increased inboth training groups after 8 weeks of plyometrics training onland and in aquatic sitting.

The drop height for simple plyometric box jumps usedin the present study was 10 inch and is in agreement with thestudy of Dursenev and Raeysky (1979) who stated that the

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distance dropped can be as little as a few centimeters or aslarge as 3 m.12 But the reason for the insignificant results maybe due to the fact that the optimal drop height used in the presentstudy was less as compared to study by Bobbart (1990)12 thatoptimal drop height used by athletes is around 0.3 to about 1.0m. It was found that 0.6 m is likely to be the maximum dropheight that would yield a performance optimum (Komi and Bosco,1978).12

In the present study untrained normal active college goingstudents were taken as subjects which is well supported by thestudy of Tamrakar and Brar (1999)13 who studied 30 male schoolgoing students and found that plyometric training improves legpower and is more effective than traditional training program.

But the reason for the insignificance of results may beattributed to the fact that the untrained individuals lack thenecessary strength required in lower limbs prior to plyometricstraining, as stated by Schmidtbleichar (1992) that plyometrictraining places considerable force on the musculoskeletalsystem, so athlete should have participated in strength trainingsuch as squat lift with atleast 150% of their body weight.14

In another study Medvedev et al. (1981) indicated thatsequenced training program in which an emphasis on strengthtraining precedes power training can produce superior results,particularly in measure of explosiveness.15

Another important reason which may be consideredresponsible for insignificant results is longer Amortization Phasein untrained individuals. Schmidtbleicher and Gollhofer (1982)carried out a study and found that during a depth jump of 110cm, an untrained individual responds with a period of inhibitionduring eccentric phase after landing. In contrast, the trainedindividual who responds with a period of facilitation or increasedagainst activation.16

Fatigue of the hamstrings muscles during plyometric trainingmight also be considered as a possible reason for insignificantresults. O. Spendiff, Longford and Winter (2002)17 found thatgreater decline in torque during subsequent exercise at highvelocities could be due to greater exhaustion of fatigue sensitiveType II fibres.

In a similar study Armstrong et al. (1983) reported thatrepeated eccentric contraction may cause fatigue which leadsto reduction in maximal muscle force and peak power.18

The results of the present study show statisticallyinsignificant increase in power of about 50.3% for righthamstrings at 2 bar and 30.8% for right hamstrings at 4 bar.Similarly left hamstrings at 2 bar show increase power of about27.6% where as the left hamstrings at 4 bar then is increase ofabout 22.5% which is in agreement with William (2002) whofound that complex training improves muscular power andathletic performance.19 Similarly agreed by Jay et al. (1987)who stated that participating in combined 8 weeks program ofplyometrics and weight training will improve leg strength andpower.6

However the result of the present study show that thestrength ratios for both legs Hamstrings Torque, Angular Velocityand Power after 4 weeks of complex plyometrics training didnot show any statistically significant results.

The reason for insignificant results may be due to the factthat the rest period between sets of hamstrings curls used inthe present study was small (30 sec) which is in disagreementwith the study of Robinson et al. (1995)21 that there was 7%increase in squat performance after 5 weeks of training when 3min rest period was used as compared to only a 2% increasewhen 30 sec rest period was used.

According to Pincivero et al. (1997) significantly greaterstrength gains (5-8%) were seen with 160 sec rest interval ascompared to 40 sec interval.22

Dawson et al. (1997), Fleck (1983), Volek and Kraemer(1996) and Robinson (1995) documented that strength andpower performance is dependent on anaerobic metabolism. Asmajority of phosphogen repletion occur with in 3 mins rest period

and removal of lactate and hamstrings may require at least 4mins.20

The reasons for insignificant results in the present studymay be due to the fact that fixed resistance load for hamstringscurls was used for all the subjects through out the trainingprotocol. This study is in disagreement with the study conductedby Mathew R. et al. (2003) that there is need to increase thetraining load (progression) to sufficiently overload theneuromuscular system as one becomes more accustomed totraining.23

Similarly agreed by Borst et al. (2001) and Marx J. et al.(2001) that long term progression oriented studies support thecontention that higher training volume is need for furtherimprovement.24

The present study was carried out with the aim of studyingthe comparison of efficacy between simple and complexplyometrics training. The results of the study did not show anysignificance and are in agreement with study of Kramer et al.(1993)25 that no significant changes were observed post trainingbetween standard (weight training plus ergometer training) andstandard plus plyometrics training for 24 females rowers after 9weeks.

Similarly agreed by Ebben et al. (2000) that performingplyometrics in complex training is as effective as performingthem in non-complex fashion.26

The results of the present study may be insignificant dueto the variations in height, age and weight of the individualsselected for the study. The influence of which has not been takeninto consideration in the present study. Intra individualdiscrepancies from the general trend may be due to varyingmuscle fibre composition (Tihanyi and Feckete 1982) and (Scharfand Noach 1994).

Present study is limited to the strength characteristics ofhamstrings. It was found that hamstrings muscles are tonicmuscles containing mainly type I fibres responsible mainly forendurance (P. Kannus et al. 1992).27

Semmler and Enoka (2000)28 found a strong positivecorrelation between body mass to height ratio and musclesphysiological cross-sectional area and muscle force generatingcapabilities. Similarly agreed by (Abernathy et al. 1994) whofound that fibre characteristics and changes in fibrecharacteristics have been identified as factors which maymodulate strength and power performance.29

Conclusion

It was observed that there was no significant difference forHamstrings Torque, Angular Velocity and Power before and aftersimple plyometrics training for right and left side at resistance 2bars and 4 bars. Similarly the values for Torque, Angular Velocityand Power for right and left side hamstrings did not show anysignificant differences before and after complex plyometricstraining at both levels of resistance i.e. 2 bars and 4 bars.T h eresults of the study showed non-significant difference inhamstrings Torque, Angular Velocity and Power between bothgroups of simple and complex plyometrics training. However,the findings of the study show statistically insignificant increasein power for both right and left side hamstrings in both Group Aand Group B after 4 weeks of training.

Clinical Relevance

Though the results of the present study are statisticallyinsignificant, there lies some non-significant increase in powerfor both legs hamstrings for simple and complex plyometricsgroups. But this statistically insignificant increase in power ismore in case of complex plyometrics group which signifies thefact that complex training is better than the simple training andthus can be useful in strengthening and rehabilitation ofhamstrings after ACL injury and also post hamstrings injury. Heidt


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et al. (2000)30 reported that female soccer players whosepersonal conditioning program included plyometrics training forhamstrings had a 2.4% ACL injury rate where as who had notbeen trained with plyometrics had 3.1% ACL injury rate. It wasfound that female athletes who did not participate in jump trainingprogram had an ACL injury rate 3-6 times greater than for trainedfemale athletes (Hewett, 1996). 31

References

1. Sale DG. Testing strength and power. (1991) cited in PeterAbernethy, Greg Wilson and Peter Logan. Strength andpower assessment. Sports Med. 19(6):401-417, 1995.

2. William E. Prentice. Rehabilitation techniques in sportsmedicine. 2nd Ed., p. 53, 1994, Mosby Publications.

3. Bosco C, Komi PV (1979) cited in (2).4. Lundon P. (1985) cited in (2).5. Mathew R. Kutz. Theoretical and practical issues for

plyometric training. NSCA’s Performance Training Journal,Vol. 2, No. 2, pp. 10-12, April 2003.

6. Jay B. Blekeyl and Dan Sauthard. The combined effect ofweight training and plyometrics on dynamic leg strengthand leg power. Journal of Strength and ConditioningResearch, Vol. 1, No. 1, pp. 14-16 (1987).

7. William (2000) cited William P. Eben. Complex training areview. J. Sports Sci and Med., 2002, 1:42-46.

8. Hewett, T.E., Stroupe, A.L., Nance, T.A. and Noyes, F.R.Plyometric training in female athletes decreased impactforces and increased hamstring torque. Am. J. Sports Med.,1996, 24: 765-773.

9. Leubbexs, Paul E., Potteiger, Jeffrey A., Hilver, MathewW., Thyfault, John P, Corper, Michael J, Lockwood, RobertH. Effects of plyometrics training and recovery on verticaljump performance and anaerobic power. Journal of Strengthand Conditioning Research, Vol. 17, No. 4, pp. 704-708(2003),

10. William et al. (1996) cited in (7).11. Leah E. Robinson, Steven T. Devor and Janet Buckworth.

The effects of land Vs aquatic plyometrics on power, torque,velocity and muscles soreness in women. Journal ofStrength and Conditioning Research. Vol. 18, No. 1, pp.84-91 (2004).

12. Dursenev and Raeysky (1979), Bobbart (1990) and Komi& Bosco (1978). cited Adrian Lees and Emed Fahmi.Optimal drop heights for plyometric training. Ergonomics.1995, Vol. 37, No. 1, p. 141-148.

13. Tamrakar Anita and Brar T.S. The effects of plyometric pushups and jumps on the development of body segmentalpower. J. Sports Traumatol. Allied Sports Sci. 1: 42-47(1999).

14. Schmidtbleichar (1992) cited Schmidtbleichar (1994).Training for power events. Strength and power and sports.381-395, Blackwell Sciences: London.

15. Mednedev (1981). cited Steven J. Fleck and William J.Kraemer. Designing resistance training programs. 3rd Ed.,p. 158-186, 2004, Human Kinetics.

16. Schmidtbleichar and Gollhofer (1982). cited Adams, K.,O’Shea, J.P., O’Shea, K.L., Climstein, M. The effects of sixweeks of squat plyometric and squat plyometric training onpower production. J. Applied Sport Sci. Research 6(1): 36-41.

17. O. Spendiff, NT Longford and EM Winter. Effect of fatigueon torque-velocity relation in muscle. Br. J. Sports Med.2002, 36: 431-435.

18. Armstrong, R.B., R.W. Ogilive and J.A. Schwane (1983).cited Vojko Strojink and Paavo K. Komi. Fatigue aftersubmaximal intensive stretch shortening cycle exercise.Med. Sci. Sports. Exs. Vol. 32, No. 7, pp. 1314-1319, 2000.

19. William P. Ebben. Complex training a review. J. Sports Sci.and Med., 2002, 1:42-46.

20. Steven J. Fleck (1983). Designing resistance trainingprogram. 3rd Ed., p. 158-186, 2004, Human Kinetics.

21. Robinson (1995) cited in (20).22. Pincivero (1997) cited in (20).23. Mathew R. (2003) cited in (20).24. Burst (2001) and Morr J. (2001) cited in (20).25. Kramer JF, Morrow A, Leger A. Changes in rowing

ergometer, weight lifting vertical jump and isokineticperformance in response to standard and standard plusplyometric training programs. Int. J. Sports Med., 1993, Nov.14(8): 449-54.

26. Ebben et al. (2000) cited in (19).27. P. Kanners, D. Alosa, L. Cook, R.J. Johnson, P. Renstrom,

M. Pope, B. Beynnon, K. Yasuda, C. Nichols and M. Kaplan.Effect of one legged exercise on the strength, power andendurance of contralateral leg. Eur. J. Appl. Physiol., 1992,64: 117-126.

28. Semmler and Enoka (2000) cited. William D. Mc Ardle,Frank J. Katch and Victor L. Katch. Exercise physiology,energy, nutrition and human performance. 5th Edition, p.519-543, 2001; Lippincot Williams and Wilkins.

29. Abernathy PJ, Jurimar J, Logan PA et al., Acute and chronicresponses of skeletal muscle to resistance exercise. SportsMed. 1994, 17: 22-38.

30. Rober S. Heidt, Jr., Lisa M. Sweeterman, Richelle L.Carlonas, Jeff A. Tarub and Francis and Tekulue. Avoidanceof soccer injuries with preseason conditioning. Am. J. SportsMed., 28: 659-662 (2000).

31. Cited in (18).


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Translation and Adaptation of Shoulder Pain and Disability Index(SPADI) into Hindi-Part 1Neha Sharma1, Shallu Sharma2, Chitra Kataria3

1 MPT, Musculoskeletal, ISIC Institute of Health and Rehabilitation Sciences, New Delhi, 2Research guide, Lecturer, ISIC Institute ofHealth and Rehabilitation Sciences, New Delhi, 3Research guide, Principal, ISIC Institute of Health and Rehabilitation Sciences,New Delhi

Neha Sharma / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Objective

To translate and adapt the original English version ofShoulder Pain and Disability Index

(SPADI) into Hindi.

Methods

The procedure followed for the translation of SPADI intoHindi was in accordance with the

Guidelines laid by American Academy of OrthopaedicSurgeons (AAOS) Outcomes Committee. The

SPADI was successfully translated from source languageinto Hindi. Minimal discrepancies were found

during the process with respect to the concept and constructwhich were taken care with successive forward

and backward translations. The translation produced usingthe AAOS model was pretested on selected subjects

in order to achieve a promising Hindi version of SPADI.

Results

The translation undertaken using the six step processrevealed no major difficulties in the construct

and concept transference. Necessary efforts were madeto achieve semantic, conceptual and experimental

Equivalence between the source and target languageversions. Following mutual consensus and repeated

pretesting, the finalized Version (SPADI-Hindi) wasprepared.

Conclusion

SPADI-Hindi is a well translated and adapted instrumentfor use in patients with musculoskeletal shoulder pathologies.

Key Words

Translation, Adaptation, SPADI-Hindi, Self reportedShoulder Pain Questionnaire.

Introduction

The Shoulder pain is a common entity amongst variousmusculoskeletal disorders reported.1,2 It is a frequent complaintby old age people, drivers, manual material handlers, farmers,athletes and significant others who are involved in repetitivetasks involving shoulder joint.3-8The documented rate of afflictionwith Subacromial Impingement Syndrome for competitive

Address for correspondence:Neha SharmaMPT, Musculoskeletal, ISIC Institute of Health andRehabilitation Sciences, New DelhiE: mail. [email protected]

swimmers in India is as high as 35%.9 According to a study byDhillon et al, the Shoulder is the second most common jointaffected in golf after low back pain with an incidence of 22.7%.10

In the assessment of Shoulder pathologies, objectivemeasures for muscle strength and range of motion depend ontherapist skills/ practice and competence (MMT, Goniometery).In the light of recent trends, the focus is gradually tilting towardsthe use of patient rated outcome measures which in turn providea holistic perspective of the patient’s discomfort. These patientcentered questionnaires are more decisive for both the diagnosisand subsequent therapeutic management and are effective toolsto adjudge the treatment outcome. 11-14

Among the various patient reported outcomes available forShoulder; the Shoulder Pain and Disability Index (SPADI) 15 andthe Disabilities of Arm, Shoulder and Hand (DASH) 16 are mostextensively used for upper extremity disorders, of which, SPADIis specific to the shoulder joint. The SPADI in English is a valid,reliable, responsive and feasible to implement outcome tool inclinical practice.17-22 It consists of 13 items which are subdividedinto pain and disability domains. The Pain dimension comprisesof five items which measure the intensity of pain in variedsituations. The disability subscale consists of eight shoulderspecific activities. Disability associated with functional tasks isassessed from the degree of difficulty an individual faces in theseactivities. To answer the questions, the patient is required toplace a mark on a 10 cm line (visual analog scale) next to eachquestion. The line is divided into 12 equal length segments andthe item score is the response marked by the patient divided by11. The percentage scores for both the dimensions are averagedto derive the total score.15

The SPADI English (Source Language Questionnaire/SLQ)has been validated in various musculoskeletal pathologiesaffecting shoulder complex including Subacromial ImpingementSyndrome (SIS), Adhesive capsulitis, Acromioclavicular jointarthritis, Glenohumeral Dislocations/Subluxations, Fractures,Post operative cases like Arthroplasties etc.17-22 It has beensuccessfully translated into German, Turkish and Slovenelanguages.23-25

With the view of expanding the use of self reported outcomemeasures for shoulder in India, the present study aims attranslating and adapting the Shoulder Pain and Disability Index(SPADI) into Hindi language.

Methodology

In order to produce a sensitive Hindi version, all thenecessary prerequisites (Permission, Identification of guidelines,Selection of translators, Formulation of bylines etc.) werefulfilled.26 The target language for translation was operationallydefined as standard Hindi which is the official language as perthe constitution of India.27-29 The developers were activelyinvolved for concept clarifications during the process. For thestudy, the original VAS version of SPADI was used as it providedwith an interval/ratio data30, 31. The translation was carried inaccordance with the guidelines by the American Academy ofOrthopaedic Surgeons32. The procedure recommends a stagedprocess with written report at every step.

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Step One: Forward translation

In this step, the English version of the SPADI (SLQ) wastranslated into standard Hindi (target language) by four bilingualtranslators who had Hindi as their mother tongue and wereproficient in spoken and written English along with Hindi. Thetranslator one (T1) was from medical background. AnOrthopaedic Surgeon (T1), thus helped in obtaining a more likelyconcept equivalent of SPADI in clinical settings. The other threetranslators (T2, T3 and T4) were qualified professional translatorsfrom various government institutions (Naive translators) whoprovided with layman Hindi language translations with multipleoptions for various words in the questionnaire. All the translatorswere given instructions to produce a concept equivalent of theSLQ with no particular emphasis on literal meanings.

Step Two: Synthesis of translation

A reconciliation process was undertaken in presence oftwo physiotherapists (Methodologists) and a peer counselor.Working from the translations produced by T1, T2, T3 and T4, aconsensus on to a single Hindi version was achieved throughfinal discussion.

Step Three: Back translation

The single Hindi version of SPADI thus prepared, wastranslated back to English (Source Language) by twoindependent Back translators, B1 and B2. These translators wereblind to the original source language version of SPADI and werenot aware of the concept being explored. According to theguidelines, the back translators should have source language(English) as their mother tongue and also be aware of the targetlanguage i.e. Hindi. For the study this condition could not befulfilled, therefore with permission from the developer,professional Hindi speaking Indian translators with MA/PHDqualifications in English were selected to translate SPADI backinto English. The process of Synthesis - Back Translation -Synthesis was repeated multiple times with the help of forwardand back translators to achieve a Synthesized Hindi version ofSPADI which most closely reflected the construct and conceptof SPADI (SLQ).

For the study, the process was repeated thrice until thetranslated document was mutually agreed to be equivalent andunambiguous.

Step Four: Expert committee review

The expert panel in the process of translation of SPADIcomprised of all the Forward translators (T1, T2, T3, and T4),Back translators (B1and B2), a Peer counselor, an Orthopaedicsurgeon, the Methodologists and a Hindi language professional.All the members of the expert committee were given a bookletwhich outlined their role on establishing equivalence betweenthe source and the synthesized version. The booklet encloseda preface, the Source language SPADI and the SynthesizedHindi version of SPADI. Forward and backward translations weremade available to them on respective demand. The bookletincluded a table which had all the 13 items from the synthesizedHindi version of SPADI on the extreme left which had to be ratedby the expert panel on six questions as described below. Themembers were asked to place a tick (“) if the items on the leftagree to the questions above or else, a cross (×).

1. Do you think the words in synthesized Hindi version havethe same meaning as Source language version?

2. Are there any words with multiple meanings?3. Are there any grammatical errors?4. Any idioms/ colloquial noticed?

5. Do you think it measures the same concept as sourcelanguage version?

6. Do you think the items capture the experiences of daily lifein the target language culture?

The panel members were asked to write the additionalcomments with respect to each item in a separate column ofsuggestions provided for every item. Considering all therecommendations suggested by the expert committee, a finalconsensus was achieved from all the members on everyquestionable item, which resulted in formulation of the Pre-finalversion.

Step Five: Testing of the Pre final version.

The Pre-final version of SPADI prepared by the expertcommittee was now used for field testing. The Pre-final version,along with source language questionnaire was provided to 20bilingual subjects (10 symptomatic shoulder pain patients and10asymptomatic subjects). Each individual was asked to rate the13 items with respect to six questions given in the Table-1.Suggestions for improvement were stated by writing the itemnumber and the relevant suggestions in the subsequent column.

Adjusting the suggestions put forward by the pretestinggroup, the finalized version, SPADI-Hindi was prepared whichwas accepted by all the expert committee members.

a) Do you think SuggestionsSPADI-Hindi is Yes Norelevant to yourshoulder condition?

b) Are you able to Suggestions:understand theinstructions and Yes Nomarking schemefor SPADI- Hindi?

c) Are you able to Suggestions:clearly understandand comprehend Yes Nothe words ofSPADI-Hindi?

d) Is the layout Suggestions:and font size of Yes NoSPADI-Hindiappropriate?

e) Do you think Suggestions:both the questionnaires are measuring Yes Nothe same conceptequally?

Table 1: Testing of the Pre final version.

Step Six: Submission of reports of thefinalized version (SPADI-Hindi) to theDeveloper for their approval.

The Finalized version (SPADI-Hindi) prepared, was put upfor appraisal to the developer of SPADI (Ms. Kathryn Roach,Associate Professor, Assistant Chair – Research, University ofMiami, Coral Gables, FL) along with the written reports.

Results

The SPADI-Hindi was acknowledged and accepted by the


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developer of SPADI. The SPADI-Hindi produced to the Hindispeaking population suffering with Shoulder pain provided agood evidence for its face validity.

The initial step of forward translations highlighted theoptions which were culturally relevant to the Indian context.32-34

In the Synthesized Hindi version of SPADI, Indian dressing attirelike, “Baniyaan”, “Kurta”, “Salwar” and “Pajamas” were includedin the item three, four and five of the disability subscale. “Tenpounds” of weight was replaced by “Four Kilograms” in the itemseven of the disability subscale in accordance with SI units. Instep one, the translators found it difficult to interpret and translatethe “Worst pain imaginable” phrase in the response option. Fromthe various options available, “Asehniye dard” was accepted asthe nearest concept and language equivalent of the same. TheStep 2 highlighted the word “Manak” for scale in the SynthesizedHindi version of SPADI which was replaced by “Mapak”. Step 4of the translation revealed certain grammatical errors, which werecorrected simultaneously.

During the testing of the Pre-final version, all the subjectsagreed that the Hindi questionnaire was relevant to theircondition of shoulder. 50% of the subjects reported difficulty inreading and understanding certain literally translated words inthe instructions of Pre-final version (“Pratyek”, “Bilkul”,“Nimnlikhit”, “Darshayi”) which were hence exempted from theinstructions while producing a conceptually equivalent translationin step 5. 95% of the subjects agreed that both the questionnairesequally measure the same concept. 40% of subjects reportedinability to interpret and understand the marking scheme whichwas in line with the SLQ. They reported two issues. One was oflanguage and the second was the dimensions along the line tomark the scores. The first problem was overcome by simplifyingthe language and replacing the word “Mark” by “Point”. For thesecond issue, the confounding dotted lines and the score spaceas on the SLQ were erased. It was seen that by providing priorinstructions of considering the line as the available range andplacing a point on it, tremendously increased the clarity torespond. The patients were now able to rate on the line betweenno pain and intolerable pain with 100% clarity and no reporteddifficulty.

Keeping in mind the suggestions given by the pretestinggroup, the font of the pre-finalized version was changed for bettervisibility and legibility of the words.

With the stated amendments, a Finalized version (SPADI-Hindi) was prepared, which the patients were able to completein an average time of five minutes. Considering the issue ofcalculating scores on VAS, the scoring of SPADI was discussedwith the developer. With the developer’s consent, the scoring ofSPADI-Hindi was simplified by dividing the item responses by10instead of 11, with division of line into 11 segments instead of12. This eased the calculations using a standard ruler.

Discussion

The Shoulder pain has been identified as a universalcondition causing discomfort and physical disability resulting inextensive use of health care resources.35, 36 Many validatedoutcome measures exist for evaluating the level of pain andfunctional disability in patients with Shoulder pathologies.15, 16,

37-40 The Shoulder pain and disability index (SPADI) is one suchself reported, joint specific measurement tool which has beenproven to be valid and highly responsive in variousmusculoskeletal pathologies affecting Shoulder complex. 17, 19-22

It was interesting that many self reported tools for Shoulderincluding SPADI, were developed in English language, whichlimits their clinical use in non English speaking countries likeIndia. The present study described the translation and adaptationof SPADI for its use in Hindi speaking population of India.

Hindi is one of the 22 official languages, most widely spokenin India, accounting for 41% of native speakers. Apart from India,it is spoken in 16 other countries mostly in the region of South

Asia. It has around thirteen dialectal forms including Khariboli,Kanauji, Bundeli, Bagheli, Chattisgarhi etc. but the study placedspecial emphasis on translating SPADI into standard Hindi inDevnagiri script which is considered official by the constitutionof India since 1958. According to the Indian census (2001),422,048,642 people in India regarded Standard Hindi as theirmother tongue and is spoken in all the Northern states of India.2729

There are numerous sets of guidelines available fortranslation, but the framework remains same with majoremphasis on gaining the equivalence between the source andtarget language version.26,41,42 The procedure and guidelines asstated by the AAOS committee were chosen for the current studyin an effort to achieve highest degree of agreement with thesource language version..

During the reconciliation of the forward translations in step2, certain words were supplemented to remove the gender biasin dressing and to meet the cultural needs of Indian people.This Decentring process helped in solving the Semantic andconceptual issues when translating questionnaires.43,44 Fourkilograms or more weight which was the appropriate metricequivalent to 10 pounds was added to equate the item to thesame degree of construct between the source and targetlanguage. In order to achieve a closest translation of SLQ, backtranslations of the synthesized version were performed in sourcelanguage (English) to highlight the discrepancies in the forwardtranslations. The procedure further ensured conceptualequivalence of the translation and underlined the wrong wordsor mistranslations which were overlooked in the previous steps.

Since SPADI is a fixed response questionnaire, itstranslation using the sequential steps of forward and backtranslations ensured maximum equivalence with SLQ which webelieve will help in achieving high internal consistency of thetranslated version.

The use of equally qualified multiple professional translatorshelped in negating the individual bias of writing style, preferenceof words, and competence. The importance of literal, culturaland conceptual adaptation has been emphasized and addressedduring the whole process to avoid word to word translation.

The cross cultural adaptation of SPADI could not beestablished since the content and layout of items as seen bythe methodologists were less cultural specific and more conceptsspecific. Even though cultural difference between sourcelanguage and Hindi do exists, repetition of steps 3, 4, 5 and 6helped in attaining a homogenous and cohesive version ofSPADI-Hindi. Moreover cross cultural adaptability can best beensured when simultaneous translation process is followed forquestionnaire development and translation.

The study provides us with the translated and adapted Hindiversion of SPADI (SPADI-Hindi) which has good face validity. Itis highly recommended that before its application in the clinicalsetting, its psychometric properties be explored.

Conclusion

The six step process adopted produced an effectivetranslated and adapted Hindi language translation (SPADI-Hindi)of the Shoulder Pain and Disability Questionnaire through acollaborative team approach.

Acknowledgements

I wish to thank Ms. Shallu Sharma, for her guidance,precious time and contributions in the study. I must also conveymy sincere thanks to Mr. Vijay Kumar Sharma, Ms. Uma Sharma,Ms. Seema Dubey, Dr. Amarjeet Singh, Dr. Kusum Agarwal &Mr. Rajeev Kumar for forward and backward translations. Mygratitude is also extended to Ms. Ruby Aikat, Dr. Ritabh Mittal,Dr. Neerajana Shokeen, and Mr. Shivjeet Singh Raghav for theirexpert comments.


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References

1. Kay Stevenson. Evidence based review of shoulder pain.Musculoskeletal Care. 2006;4: 233-239.

2. Bongers P M. The cost of shoulder pain at work. BMJ2001; 3(22): 64-65.

3. Gaur G. Ray Musculoskeletal disorders in the Indiancontext, India Asian-Pacific Newsletter 3/1998 p.56-59.

4. Dr. Ahana Chatterjee, Dr Ashok Kumar Midya, Dr. ApurbaBarman; Various pathologies causing shoulder pain: Theirrelationship with demographic parameters and co-morbities.Indian Journal of Physical Medicine and Rehabilitation2008; 19(2):32-36.

5. Musculoskeletal disorders and body part discomfort whilecarrying heavy loads by hill women. International ErgonomicConference 2009 HWWT; Dec 17-19.

6. A Leclerc, J Chastang, I Niedhammer, M Landre, YRoquelaure. Incidence of Shoulder Pain in Repetitive work.Occup Environ Med. 2004 January; 61(1): 39–44.

7. D P Pope, P R Croft, C M Pritchard, A J Silman, G JMacfarlane. Occupational factors related to shoulder painand disability. Occup Environ Med. 1997 May; 54(5): 316–321.

8. Oberlander, Chisar, Michael A. Epidemiology of ShoulderInjuries in Throwing and Overhead Athletes. SportsMedicine and Arthroscopy Review June 2000; 8(2).

9. Sneh Bansal, Akoury Gaurang, Kumar Sinha, Jaspal SinghSandhu Shoulder Impingement syndrome amongcompetitive swimmers in India—prevalence, evaluation andrisk factors. J Exercise Science Fit. 2007 ; 5(2).

10. Mandeep S Dhillon, Sanjay Singh, Himmat Singh Dhillon,Jaspal S Sandhu. Epidemiology of golf relatedmusculoskeletal injuries. Indian journal of Orthopaedics2008; 40 (3):188-90.

11. WHO ICF Classification. Lippincott & Williams, Geneva,2001.

12. Patient-reported outcome measures: The importance ofpatient satisfaction in surgery 2009; 146 (3), 435-443.

13. James G Wright. Evaluating the outcome of treatment:Shouldn’t we be asking patients if they are better? Journalof Clinical Epidemiology 2000; 53, Issue 6: 549-553.

14. Outcomes and effective pain treatment. Pain, Clinicalupdates. International Association for the study of pain.January, 2008 ; Volume XVI, Issue1.

15. Kathryn Roach, Elly Budiman-Mak. Development ofShoulder Pain and Disability Index. Arthritis Care andResearch 1991; 4:143-149.

16. Hudak PL, Amadio PC, Bombardier C. Development of anupper extremity outcome measure: the DASH (Disabilitiesof the arm, shoulder and hand) [corrected]. The UpperExtremity Collaborative Group (UECG) Am J Ind Med. 1996Jun; 29(6):602-8.

17. Susan N Heald, Daniel L Riddle. The Shoulder Pain andDisability Index: The construct validity and responsivenessof a region specific disability measure. Physical therapy1997; 77:10:1079-88.

18. Phillip Mc Clure, Lori Measures of Adult Shoulder Function.Arthritis & Rheumatism 2003; 59:5:S50-S58.

19. Joy Macdermid et al .The shoulder pain and disability indexdemonstrates factor, construct and longitudinal validity.BMC Musculoskeletal disorders. 2006 ; 7:12.

20. John W Williams Jr, Donald R Holleman Jr. MeasuringShoulder Function with the Shoulder Pain and DisabilityIndex. Journal of Rheumatology 1995, 22: 727-32.

21. Einar Kristian tveita et al. Factor structure of Shoulder Painand Disability Index in patients with Adhesive Capsulitis.BMC musculoskeletal disorders. 2008, 9:103.

22. A Paul, M Lewis A comparison of four shoulder specificquestionnaires in primary care. Annals of Rheumaticdisease 2004 ; 63:1293-99.

23. F.Angst, J.Goldhahn G. Pap, A. F. Mannion Cross-culturaladaptation, reliability and validity of the German ShoulderPain and Disability Index (SPADI) Rheumatology 2007;46(1):87-92.

24. Gonca Bumin, Emine Handan Tuzun. The Shoulder Painand Disability Index (SPADI): Cross-cultural adaptation,reliability and validity of the Turkish version. Journal of Backand Musculoskeletal Rehabilitation 2008; 21:57-62.

25. Jamnik H, Spevak MK. Shoulder Pain and Disability Index:Validation of Slovene Version.International Journal ofRehabilitation Research 2008 Dec; 31 (4), 337-41.

26. Diane Wild, Alyson Grove, Mona Martin Principles of goodpractice for the translation and cross cultural adaptationprocess for patient reported outcome (PRO) measures:Report of the ISPOR Task force for translation and crosscultural adaptation value in health. 2005; 8: (2):94-104.

27. Official Language–Constitutional Statutory Provisions.Article 343(1).

28. India.gov.in for Government documents English Article 243395 184pp.

29. Censusindia.gov.in30. Wall and Melzack’s Textbook of pain. 5th Edition, Elsevier.31. Research Methods for clinical therapists: Applied Project

Designs and Analysis. Carolyn Hicks. 4th Edition, 2004,Churchill Livingstone.

32. D E Beaton,C. Bombardier, F. Guillemin and M. Bosi Ferraz.Guidelines for the process of cross cultural adaptation ofself reported measures. Spine 2000; 25:24:3186-3191.

33. Ferraz MB. Cross cultural adaptation of questionnaires whatis it and when should it be performed?.Journal ofrheumatology 1997, 24:25, 2066-68

34. Relevance of cross cultural adaptation and clinimetrics forphysical therapy instruments. Rev.bras.fisioter 2007,11:4,245-252.

35. L Badcock, M Lewis, E Hay, R McCarney, P Croft. Chronicshoulder pain in the community: a syndrome of disability ordistress? Ann Rheum Dis. 2002 February; 61(2): 128–131.

36. Van der Windt DA, Koes BW, De Jong. Shoulder disordersin general practice, incidence, patient characteristics andmanagement. Annals of Rheumatic diseases: 1995; 54:959-64.

37. Richards R.R.; Bigliani, L.U.; Friedman, R.J.A standardizedmethod for assessment of shoulder dysfunction. J ofshoulder and elbow surgey.1994; 3: 347-52

38. John C. L’Insalata, Russell F. A Self-AdministeredQuestionnaire for Assessment of Symptoms and Functionof the Shoulder. Journal of Bone and Joint Surgery -American May 1997, 79-A: 5.

39. G.van der Heijden. Shoulder disability questionnaire designand responsiveness of a functional status measure.Journalof Clinical Epidemiology, Volume 53, Issue 1, Pages 29-38.

40. Lippitt SB, Harryman DT, Matsen FA.A practical tool forevaluation of function: The Simple Shoulder Test: Americanacademy of Orthopaedic surgeons; 1993:501-30.

41. M Herdman, J. Fox Rushby and X Badia. ‘Equivalence’and the translation and adaptation of health related qualityof life questionnaires. Quality of Life Research 1997; 6: (3)237-47.

42. Cheng-Chih Lee, Denise Li, Shoshana Arai. EnsuringCross Cultural Equivalence in Translation of ResearchConsents and Clinical Documents. Journal of Trans culturalNursing. 2009; 20 (1); 77-82.

43. Harkness J and Schoua-Glusberg A. Questionnaires intranslation. ZUMA-Nachrichten Special 1998; January: 87-126.

44. Translating questionnaires and other research instruments,Problems and solutions. Orlando Behling, Kenneth S. Law.2000. Sage Publications.


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Comparision of Musculoskeletal Symptoms Among Adult FemaleCaregivers of Physically Challenged Children and Normal ChildrenParul Raj1, Amitesh Narayan2, Sailakshmi Ganesan3

1Lecturer, Dept. of Physiotherapy, Manipal College of Allied Health Sciences, Manipal, India, 2,3Associate Professor, Dept. ofPhysiotherapy, Kasturba Medical College, Mangalore

Parul Raj / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Purpose

To compare the musculoskeletal symptoms in adult femaleprimary caregivers of physically challenged children with that ofnormal children.

Methods

30 caregivers (18-40Yrs) of physically challenged children(1-5 Yrs) and 30 caregivers of normal children of same agegroup were selected through convenient sampling method.Nordic Questionnaire was administered to each group. Dataanalysis done using Mann-Whitney U test and Student unpairedt-test to compare the mean difference between the groups.

Results

Caregivers of physically challenged children developedmusculoskeletal symptoms (93%) compared to that of normalchildren (60%)(p=0.002). Among all musculoskeletal symptoms,Low Back trouble (a/c Nordic questionnaire) was most

Common (76.7%) in caregivers of challenged children (P=0.008), the next commonly involved part was shoulder (36.7%).

Conclusion

Our study concluded that female caregivers of physicallychallenged children had higher rate of musculoskeletalsymptoms as compared to normal. Therefore it is suggestedthat caregivers must adapt measures to prevent musculoskeletalsymptoms.

Introduction

Commonly all children enjoy healthy life with little or nospecial needs, but some children have difficulty in early life aswell as later on due to developmental disorders requiring specialattention/assistance by parents/caregivers for all their functionalactivities and self care.1 These activities cause additionalphysical stress on the parents/caregivers leading to developmentof various musculoskeletal symptoms (due to increasing needsof a challenged child with growing age).

It is not known why some caregivers who are involved withthe care of a physically challenged child cope well while othersdo not. It is also known that psychological and physical healthof caregiver is strongly influenced by a physically challenged

Address for correspondence:Mrs.Parul RajLecturerDepartment of Physiotherapy, MCOAHS, Manipal-576104(India)E-mail: [email protected] Ethical Committee Approval obtained on October-2007

child’s behavior and demands of care.1 Greater knowledge ofcaregiver’s health related needs would allow for the improvementof existing services and the development of new strategies tosustain caregivers in their vital role.2 It has been found that aneducated mother or caregiver commonly follow better ergonomictechniques related with child care and so have less work relatedinjury.3 It was also observed that knowledge of ergonomics inchild care reduces the chances of musculoskeletal pain.Suggestions were also made for the need for childcare taskanalysis and identification of effective methods to reduce therisk of musculoskeletal pain.4

There are significant literature dedicated to studying theburden placed on caregivers of both elderly persons and childrenwith disabilities. However, most of these studies have focusedon the psychological aspects of caregiver burden such as stress,depression, and social isolation.5 Also it is noted that manyparents are not able to cope well and their mental and physicalhealth is at risk.6 Females are commonly involved with caregivingneeds of special children and so they are subject to psychologicaland physical stress.1, 7 Therefore the need to analyzemusculoskeletal symptoms among them become important.

Nordic questionnaire serves as an instrument in screeningof musculoskeletal disorders in an ergonomic context inoccupational setting so it may help us in screening themusculoskeletal symptoms in these caregivers who requiresrepeated lifting or carrying the child.

Literature suggests that about 10% of children experiencedevelopmental disorders requiring access to the health caresystem and extensive caregiving, often throughout childhoodand into adult years .8 Caregiving demands of such childrencontribute directly to both psychological and physical health ofthe caregivers.1

Sanders et al found that 66% parents/caregivers of normalchildren (<4 years of age) had high prevalence ofmusculoskeletal symptoms. They also noted incidence of lowback symptoms (48%), neck (17%), upper back (16%) andshoulder (11.5%) among these caregivers.9

Factors associated with musculoskeletal pain whileperforming child-care tasks was defined as having highbiomechanical risks.9

Studies indicate that females (94.4%) are more involved incare-giving needs of disabled child compared to male.(1, 7)

Another study reported high prevalence of low back pain(80.3%) among caregivers who were involved with physicallychallenged child’s care while the same was 40.5% among thecaregivers of normal children.10

Shigeki et al noted the one-month prevalence of Low backPain (LBP) among staffs in schools for physically and mentallyhandicapped children, which was approximately 45%. Therebyconfirming the need to treat and manage LBP.11

King et al (2005) reported musculoskeletal symptomsamong childcare workers and hence, stressed the need forergonomic interventions. 4

Children in age group 1-5 years require increased amountof lifting and caregiving activities. But children with physicalchallenges are relatively more dependent on their parents forthese activities. The available literature has mainly focused onpsychological components of these caregiving activities whilelittle or no retrieval data could be obtained which suggest thephysical well being of the caregivers. Thus the need for suchstudies is essential.

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The purpose of this study is to compare themusculoskeletal symptoms in adult female primary caregiversof physically challenged children with that of normal childrenand we hypothesize that there will be no differences betweenthe musculoskeletal symptoms in female caregivers of physicallychallenged children and normal children.

The findings from this study will help to identify the presenceof musculoskeletal symptoms among caregivers and so willindicate the need for prevention and intervention among suchpopulation.

Methods

It is a cross-sectional study.

Standardized Nordic Questionnaire

This is used to screen musculoskeletal disorders in anergonomic context and for occupational health care services. Itcan be used as self-administered questionnaire or throughinterviews.

It has acceptable reliability and validity with kappa value of0.88 to1.

In some studies the questionnaire has revealed a highprevalence of symptoms and disorders in certain anatomicalregions, which clearly correlate to the local physical demands.12

A cross-sectional study was conducted from August 2005to December 2007.

Subjects

30 caregivers for physically challenged children (Group 1)and 30 caregivers for normal children (Group 2) were selectedthrough convenient sampling. Group 1 was selected from Neuro-Sensory development unit and Child Developmental Centre. Fornormal children, Schools and Anganwadi (Anganwadi is agovernment sponsored child-care and mother-care center inIndia. It caters to children in the 0-6 age group. The word means“courtyard shelter” in Hindi) were selected.

Inclusion Criteria

Adult female primary caregiver, age of Caregiver 18-40 Yrs,Caring for physically challenged / normal child in age group (1-5 Yrs), Caregiver involved with only one/two child and Caregiverinvolved in caring for minimum of 1 year.

Exclusion Criteria

Male caregivers,Caregivers having history of any surgeryrelated to musculoskeletal system, Primary caregivers diagnosedwith musculoskeletal symptoms, Caregivers giving history ofmusculoskeletal /neurological symptoms before pregnancy.

Instruments

Screening form, which included the demographic data ofcaregivers & child and some questions, based on inclusion andexclusion criteria.

Standardized Nordic Questionnaire

It consists of general questionnaire, and a specific onesfocusing on the low back, neck and shoulder trouble. Thisquestionnaire serves as an instrument in the screening ofmusculoskeletal disorders in an ergonomic context and foroccupational health services.

Weighing Machine - to measure weight of child andcaregiver

Measuring Tape- to measure height of child and caregiver

Procedure

The parents/caregivers of challenged children visiting theNeuro Sensory Developmental Unit were communicated inperson about the purpose and utility of this study. Thereafter,parents who had agreed for their participation were selected,and after obtaining their signature on consent form they wereincluded in this study for further data collection.

Similarly parents or caregivers of children visiting ChildDevelopmental Center were recruited and their data werecollected accordingly.

Demographic data of children, parents/caregivers wascollected. Thereafter, based on inclusion or exclusion criteriathe normal and challenged children were screened throughdemographic data collection.

Each group was introduced to Nordic Questionnaire andwas filled by investigator.

Data Analysis

Statistical analysis was done using SPSS (version 15)software.

Chi-square and Fisher exact test was done to find out theassociation between the groups.

Mann Whitney U test and Student unpaired t-test was usedto compare the mean difference among groups.

Result Analysis

The major findings of this study was that caregivers ofphysically challenged children developed more musculoskeletalsymptoms (93%) compared to that of normal children (60%)with highly significant p value=0.002 (Table 1)

Other important finding was that among all themusculoskeletal symptoms Low Back trouble was most common(76.7%) compared to any other areas of musculoskeletal troublein caregivers of disabled children, which was statistically highlysignificant with P value =0.008 (figure 2)

The next commonly involved part was shoulder (36.7%).The data analysis indicated that other than Low back andshoulder symptoms, no other musculoskeletal symptoms werestatistically significant.

The data was further analyzed based on child’santhropometric measures (mainly height & weight) and foundthat in the age group of 1-5 years the anthropometric dimensionof the children was not significant in causing development ofmusculoskeletal symptoms among parents/caregivers (p=0.936for height & p=0.895 for weight).

The comparative analysis between mothers and paidcaregivers was not possible as, among all the caregivers ofphysically challenged and normal children, only one caregiverwas paid caregiver.

In the group 1 the largest number of children was spasticdiplegics (33.4%) among which 8 out of 10 caregivers hadsymptoms of Low back trouble (26.7%).

The other diagnosis in disabled children category wereDelayed milestone (DMS), Down syndrome, Hypotonic, Knockknee, Spastic Paraparesis, Spastic quadriplegic and in eachcategory maximum number of sample were varied between 1-7, thus statically it was not possible to compare.

With regards to number of hours of work involved withphysically challenged and normal children, musculoskeletalsymptoms were insignificant (p= 0.297).

The musculoskeletal symptoms in other areas like neck(p=0.038), elbow (p=0.163), wrist (p=0.117), hip (p=0.05), Knee(p=0.481) and ankle (p=0.492) were statistically non significantwhereas, low back (p=0.008) and shoulder (p=0.001) troubleshowed significant values.


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None of caregivers had associated risk factors like historyof accident due to caregiving needs of normal/physicallychallenged children.

Discussion

The primary aim of this study was to compare theprevalence of musculoskeletal symptoms in adult female primarycaregivers of physically challenged children with that of normalchildren.

This study indicated that caregiver of physically challengedchildren have high risk of musculoskeletal symptoms (97%)compared to the caregivers of normal children (60%). P=0.002

Among the identified musculoskeletal symptoms incaregivers of physically challenged children, low back troublewas found to be most common and its percentage was 76.7%,while the same was 43.3 % in caregivers of normal children.The reason could be that caregiving activities for the caregiverrequired use of spine to bend and use of shoulder to hold thechildren and so the symptoms in these areas.

Normal children after the age of 1 year are mobile andrequire relatively less amount of lifting or carrying compared tophysically challenged children, hence low evidence ofmusculoskeletal symptoms are noted in caregivers of normalchildren.

This indicates that the caregiving nature and demandsrelated with physically challenged children are main reason forhigh percentage of low back trouble among caregivers ofphysically challenged children.

The other findings that have been derived from this studywas that shoulder is the next commonly involved area amongcaregivers of disabled children and its prevalence rate was36.7% but in normal children it was 3.3%.

The prevalence rate of 71% of low back pain was seenamong the female caregivers of physically challenged childrenon the basis of literature14. Thus our findings are in synchronywith the previous study. The probable reason for this to happencan be linked with nature of caregiving required (like sitting forlong time, lifting, feeding while baby is sitting on mothers lap,bathing, dressing, toileting and carrying out in arms). All theseactivities have negative impact on the spine and so higherchances of back pain. In our country most of the caregivingactivities are at floor level, which requires lot of bending ascompared with western countries where most of the equipmentsare ergonomically designed for caregiving of baby’s needs andso is beneficial in preventing musculoskeletal symptoms amongthem.

Regarding involvement of shoulder in our study groups,the reason can be linked with the cultural habits of carryingchildren in their arms while going out unlike in western culturewhere they carry in pram. Thus our caregivers constantly stressnot only their spine but also their shoulder and arm muscle,which could have caused increased number of shoulder trouble(36.7%).

Since we selected female caregivers having children in agegroup of 1-5 yrs, we found that anthropometric measures ofchild didn’t contribute in causing musculoskeletal symptomsamong caregivers. The possible reason for this could be actualcaregiving activities (like lifting or carrying child) with physicallychallenged children needs, not the weight and height of the child.In this study we found the positive musculoskeletal symptomsin shoulder of caregiver of physically challenged childrencaregiver while no such symptoms were found in caregivers ofnormal children, similarly increased percentage of low backtrouble was noted among caregivers of physically challengedchildren.

Since in this study physically challenged children were fromvarious category of diagnosis, thus the study couldn’t derive ifany specific diagnosis can contribute towards development ofmusculoskeletal symptoms.

In spite of having musculoskeletal symptoms like Low backand shoulder trouble among caregivers of physically challengedchildren, it was found that statistically insignificant number ofparents or caregivers had felt the need to consult a physicianfor their musculoskeletal symptoms (p=0.845 for Low back) andso none of them were hospitalized indicating that the healthstatus of all these caregivers were very good and most of thecaregivers were in young age of their life so their musculoskeletalsystem was significantly strong to take care of their child’scaregiving needs, while no symptoms of such nature were foundin control group caregivers.

No parents or caregivers felt the need to change their jobsbecause of special needs of challenged children. Similar thingwas found with normal children’s caregivers, indicating thatparents or caregivers of age group 1-5 years could manage theneeds of the children or special children without affecting theirjobs or leisure activities.

When the data was analyzed among the parents orcaregivers with more than one child, it was found that siblingsdoesn’t cause additional work burden on their parents orcaregivers and so none of them developed any kind ofmusculoskeletal symptoms because of multiple siblings.

So this study suggests that, parents/caregivers of physicallychallenged children can be recommended for preventiveexercises for spine & arms so that development ofmusculoskeletal symptoms can be minimized maximally .Thesame can be identified through future study using exerciseregimen for caregivers of physically challenged children.


Mental state and social status of caregivers was notconsidered, Only diagnostic aspect of a developmental disorderwas considered (i.e. type of diagnosed disorder) but not thequality aspect of disorder which could have been done usingGMFCS scale (level 1 to level 5), Educational level of caregiversin both challenged and normal children was not uniform, andthe motor development in relation with caregiving nature wasnot considered in this study.

Future Research

Future research recommended are-Comparing the effects of therapeutic exercises and placebo

treatment, for the caregivers of physically challenged children.By quantifying the quality of disability by using GMFCS scale

and then analyzing the state of musculoskeletal symptomsamong caregivers of normal and disabled children.

References

1. Raina P, O’Donnell, Peter R. et al. the health and well beingof children with cerebral palsy. Pediatrics 2005 Jun; 115(6):626-636.

2. Murphy NA, Christian B, Caplin DA et al, the health ofcaregiver for children with disabilities: caregiver prospective.Child Care Health Dev 2007 Mar;(2): 180-7.

3. Maynard SA, Blain LG. women, work and children: wherehave been? Where are we going? (Abstract) work 2005;24(4): 361-367.

4. King PM, Gratz R, Kleiner K. Ergonomic recommendationand their impact on child care worker’s health. (Abstract)Work 2006; 26(1): 13-17.

5. Henry C. Tong, , Geeta Kandala, Andrew J. Haig et al.Physical functioning in Female Caregivers of Children withphysical Disabilities Compared With Female Caregivers OfChildren With a Chronic Medical Condition. Arch PediatrAdolesc Med 2002 Nov; 156:1138-1142.

6. Paul L Pimm. Some of the Implication of Caring for a Child


149

or adult with Cerebral Palsy. British Journal of OccupationalThjerapy.1996 July; 59(7): 335-341.

7. E N C.De Barros RN, Alexandre MNC. Cross-culturaladaptation of the Nordic Musculoskeletal Questionnaire.Am J Industrial Med. 1996 Jun; 29(6): 609-617.

8. Parminder raina, Maureen O’ Donnell, Heidi Schwellnus.Caregiving process and caregiver burden: Conceptualmodels to guide research and practice. BMCPediatrics.2004 Jan; 4: 1-13.

9. Sanders MJ, Morse T. The ergonomics of caring for children:An exploratory study (abstract) Am J Occup Ther 2005 May-Jun; 59(3): 285-295.

10. Tong HC, Haig AJ, Nelson VS et al. Low back pain in adult

female caregivers of children with physical disabilities. ArchPediatr Adolesc Med 2003 Nov; 157:1128-1133.

11. Shigeki MUTO, Takashi MUTO, Akihiko SEO et al.Prevalence of and risk factors for low back pain amongstaff in schools for physically and mentally handicappedchildren. Industrial health.2006, 44:123-127.

12. Kuorinka, Jonsson B, Kilbom A et al. Standardized NordicQuestionnaire for the analysis of musculoskeletalsymptoms. Applied ergonomics 1987; 18(3): 233-237.

13. Henry C. Tong, Andrew J. Haig, Virgina S. Nelson et al.Low back pain in adult female caregivers of children withphysical disabilities. Arch Pediatr Adolesc Med 2003 Nov;157:1128-1133.


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A Comparative Study of Left and Right Hand Grip Strength inDifferent Positions of Shoulder and ElbowPrashant B Mukkannavar1, Umasankar Mohanty2

1Lecturer,S.D.M College of Physiotherapy, Dharwad, Karnataka, India, 2President, Manual therapy foundation of India. MangaloreKarnataka, India

Prashant B Mukkannavar / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Background and Objectives

There are numerous daily tasks that require a stronger gripin various positions other than the standardized testing protocolfor handgrip strength. Therefore, in the clinical practice it isnecessary to understand how deviations from standard positioncan affect grip strength. This study has investigated thedifferences in left and right grip strength in different positions ofshoulder and elbow combinations.

Method

Grip strength of forty healthy subjects was tested with ahydraulic dynamometer in six testing positions. The testsconsisted of three positions, in which the elbow was maintainedin full extension combined with varying degrees of shoulderflexion (i.e. 00, 900 and 1800) and other three positions in whichthe elbow was maintained at 900 flexion combined with varyingdegrees of shoulder flexion (i.e. 00, 900 and 1800).

Results

In right hand, the highest mean grip strength measurementof 38.9 with SD 14.1, when the shoulder was positioned in 1800

of flexion with elbow fully extended. Whereas, the lowest meangrip strength measurement of 35.6 with SD 12.0 was recordedin 1800 of shoulder flexion with elbow flexed at 900.In left hand,the highest mean grip strength measurement of 36.4 with SD11.9 when the shoulder was positioned in 1800 of flexion withelbow fully extended. Whereas, the lowest mean grip strengthmeasurement of 33.5 with SD 9.2 was recorded in 1800 ofshoulder flexion with elbow flexed at 900. The results of ANOVA,in left hand showed significant difference (p=0.005) in gripstrength across all six testing positions and significant difference(p=0.0000) for the total subjects. For right hand findings ofANOVA suggested significant difference (p=0.00092) in gripstrength across all six testing positions and significant difference(p=0.0000) for the total subjects. Consequently, the Bonferronicorrection for multiple comparisons was done, yielding anexperiment-wise alpha level of 0.05. This value indicatedstatistically significant differences existed in the total sampleand among the all positions for both left and right hand. In bothleft and right hand more significant differences were found in1800 shoulder flexion with elbow flexed at 900 and 1800 shoulderflexion with elbow fully extended.

Conclusion

The changes in left and right hand grip strength observedwith variations in shoulder and elbow position. Grip strengthimproved with the increasing flexion angle of shoulder joint. It isvital that when measuring grip strength, one understands howsmall changes in body position can result in altered gripstrengths.

Key Words

Dominant hand, non dominant hand, grip strength

Introduction

Grip strength is the integrated performances of muscles bydetermining maximal grip force that can be produced in onemuscular contraction.1 It is widely accepted that grip strengthprovides an objective index of the functional integrity of the upperextremity.2,3 In addition to being an economical measure that iseasy to administer, grip strength is one of the best indicators ofthe overall strength of the limb.4 Among hand function tools,measurement of grip strength is an important component of handrehabilitation. Because it helps to establish a baseline fortreatment and it is measure of the effectiveness of therapy.5Manyof the items included in an upper extremity assessment arebased on observation and subjective impressions; however, agrip-strength measurement, when properly taken, can provideobjective and quantifiable information regarding hand function.

To obtain an objective assessment of hand function thereis a need for a standardized measure of hand strength. Americansociety of hand therapist suggested a standardized testingprotocol for handgrip strength in which subject is seated withthe shoulder adducted and neutrally rotated, the elbow flexedat 90 and forearm and the wrist in neutral position.6 However,there may be subjects who are unable to assume or hold thisstandardized testing position. Standardized grip strength testingprocedures have been recommended to provide even greaterobjectivity of measurement. In a clinical setting, however, thereare a number of reasons why it may be impossible to followstandardized testing procedures, such as a patient’s inability totolerate an upright position or the presence of contractures inupper extremity joints.

Alternative testing position may be useful, however, inidentifying positions, which maximize biomechanical abilities andmay assist in the design of environment and tools.7 Variousreports have discussed the effect of testing posture and jointposition on grip strength. Standing has been found to result inhigher grip strengths than when sitting when using the sameinstrument. Differences of up to 2lb/in (140gm/cm) have beenreported.8,9 Teraoka examined the effect of three body positionon grip strength: standing, sitting, and supine, with the elbowjoint held in full extension in each test position. He found thatgrip strength was strongest with the subject in the standingposition.10

One study has directly examined the influence of theshoulder position on grip strength. Su et al compared the strengthof the grip while the shoulder was in 0°, 90° and 180° of flexion.They found that the strongest grips were obtained while theshoulder was in 180° of flexion and the elbow extended. Theweakest grips were found while the shoulder was in 0° and theelbow in 90° of flexion. In this study only the dominant hand wastested.11

Studies on the effect of elbow position on grip strengthremain controversial. Mathiowetz et al12tested the grip strengthof 29 female college students with the elbow joint flexed at 90°in one test and fully extended in another. Significantly highergrip strength was obtained in the 90° elbow flexed position thanin the fully extended position.12 Balogun, et al 9 tested the grip

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strength of 61 college students in four positions: (1) Sitting withelbow in 90° flexion; (2) Sitting with elbow in full extension; (3)Standing with elbow in 90° flexion; and (4) Standing with elbowin full extension. Lowest scores were recorded when themeasurement was taken while the subject was sitting with theelbow joint in 90° flexion.

There are numerous daily tasks that require a stronger gripin various positions other than standard position. If grip strengthmeasure were found to vary depending on upper extremityposition, interpretation of this information could affect treatmentplanning in the clinical section. Therefore, in clinical practice itis necessary to understand how deviations from standardposition can affect grip strength.

The main objective of the current study is to establish thevariation in grip strength in different positions of shoulder (i.e.0°, 90° and 180° flexion) and Elbow (90° flexion, 0°extension)and as well as to compare left and right grip strength in differentpositions of shoulder (i.e. 0°, 90° and 180° flexion) and elbow(90° flexion, 0°extension).

Methodology

Subjects

A convenience sample of 40 healthy subjects from thestudent population of Srinivas College of Physiotherapy (21males, 19 females; mean age19.87, SD1.66 years) in age groupof 18-25 years participated in the study. Subjects signed informedconsent forms after being provided with a brief description ofthe study.

Inclusion Criteria

1. Healthy subjects in age group of 18 to 25 years.

Exclusion Criteria

1. Upper extremity abnormalities2. Any history of inflammatory joint diseases, neurological

disorder or injury to upper limb and other health conditions.3. Ambidextrous

Device

A standard adjustable hydraulic hand dynamometer whichwas manufactured in USA (fabrication Enterprises Inc) was usedfor measuring grip strength. This device was set at study andwas factory calibrated. The device was set at second handleposition (of the five positions available) and same dynamometerwas used throughout the study.

Measurement Procedure

All subjects reported themselves to be in good health. Byself report, majority of subjects were right hand dominant. Priorto the procedure subjects who met the inclusion criteria wereassessed and evaluated thoroughly. Each subject’s name,gender and age were recorded. Standard anthropometric dataof the subject’s body weight, height, upper arm length, forearmlength, and circumference of wrist were collected. Hand sizewas measured in hand at maximal width and by measuring thedistance separating distal extremes of the first and fifth digits13.Hand length was measured from distal crease of the wrist to thetip of the middle finger.14Variable related to strength, such ashand dominance was also recorded. The study was approvedby ethical committee of Srinivas College of physiotherapy.

Subjects in the standing position were instructed to adductand neutrally rotate their shoulders while holding their forearmand wrist joints neutral in the six testing positions:

1. 0° of shoulder flexion with elbow flexed at 90°(PS 1).2. 0° of shoulder flexion with elbow fully extended (PS 2).3. 90° of shoulder flexion with elbow fully extended (PS 3).4. 90° of shoulder flexion with elbow flexed at 90° (PS 4).5. 180° of shoulder flexion with elbow fully extended (PS 5).6. 180° of shoulder flexion with elbow flexed at 90° (PS 6).

Prior to the commencement of data collection, a practicetrial was given to familiarize with the dynamometer. Beforetesting, the examiner (the first author) demonstrated how to holdthe handle of the dynamometer. The same instructions weregiven for each trial. After the subject was positioned with thedynamometer, the examiner instructed the subject to “squeezeas hard as you can … harder … harder.. Relax”. To control forthe effects of fatigue, subjects were asked to rest for 2 minutes.For each hand, three trials were performed in each position.Mean of 3 trials were recorded for calculation purpose.

Results

Stratifying the 40 subjects by age and gender resulted in21 male 19 females in the age group of 18-25years. The age ofmales and females is equivalent across the age group of 18-25years, with mean age of 19.87 years (see table 1).Anthropometric variables such as height and weight are higheramong males than females. Out of total sample large majorityof subjects are right handed (82.5%).


Table 2. Represents mean and standard deviations ofsubject’s grip strength in six positions. In right hand, the highestmean grip strength measurement of 38.9 with SD 14.1 whenthe shoulder was positioned in 1800 of flexion with elbow fullyextended. Whereas, the lowest mean grip strength measurementof 35.6 with SD 12.0 was recorded in 1800 of shoulder flexionwith elbow flexed at 900.In left hand, the highest mean gripstrength measurement of 36.4 with SD 11.9 when the shoulderwas positioned in 1800 of flexion with elbow fully extended.Whereas, the lowest mean grip strength measurement of 33.5with SD 9.2 was recorded in 1800 of shoulder flexion with elbowflexed at 900.

The results of ANOVA for both left and right hand gripstrength are represented in table 3 and table4 respectively. Inleft hand findings suggests significant difference (p=0.005) ingrip strength across all six testing positions and significantdifference (p=0.0000) for the total subjects (Table3). For righthand findings suggests significant difference (p=0.0092) in gripstrength across all six testing positions and significant difference(p=0.0000) for the total subjects (Table4).

Consequently, the Bonferroni correction for multiplecomparisons was done, yielding an experiment-wise alpha levelof 0.05. This value indicated statistically significant differencesexisted in the total sample and among the all positions for bothleft and right hand. In both left and right hand more significantdifferences were found in 1800 shoulder flexion with elbow flexedat 900 and 1800 shoulder flexion with elbow fully extended.

Discussion

Measurement of grip strength is an important componentfor hand rehabilitation. It assesses the patient’s initial limitations

Table 1: Descriptive data of study subjects.

Variables Women Men Total(N=19) (N=21) (N=41)

AGE 19.7(1.3) a 19.9(1.9615) a 19.8(1.6) a

HEIGHT 155.9(4.7) a 172.0(9.4146) a 164.3(11.0) a

WEIGHT 49.2(10.5) a 61.6(6.3587) a 55.7(10.5) a

DOMINANCERIGHT 13(68.4) a 20(95.2) a 33(82.5) a

LEFT 6(31.5) a 1(4.7) a 7(17.5) a

aMEAN (SD) Range

152 Prashant B Mukkannavar / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Table 2: Mean and standard deviation of grip strength scores for both left and right hand, in all six positions.

TESTING POSITION SIDE TOTAL t VALUE p VALUESUBJECTS (N=40)

MEAN SD0° shoulder flexion with elbow LEFT 34.6 12.2 2.44 0.019*fully extended RIGHT 37.1 15.00° shoulder flexion with elbow LEFT 35.4 10.9 1.41 0.17flexed 90° RIGHT 37.0 14.390° shoulder flexion with elbow LEFT 35.4 11.8 1.85 0.072flexed 90° RIGHT 37.1 14.090° shoulder flexion with elbow LEFT 36.3 12.5 1.53 0.13fully extended RIGHT 37.6 13.2180° shoulder flexion with elbow LEFT 33.5 9.26 2.49 0.017*flexed at 90° RIGHT 35.6 12.0180° shoulder flexion with elbow LEFT 36.4 11.9 2.42 0.020*fully extended RIGHT 38.9 14.1

*Significant at 5% level of significance (p<0.05)

Table 3: Left hand repeated measured ANOVA determining grip strength differences in all six positions.

Source DF SS MSS F PPosition 5 240 3.453 3.453 0.0051Subjects 39 28370.7 52.194 52.194 0.0000

Table 4: Right hand repeated measured ANOVA determining grip strength differences in all six positions.

Source DF SS MSS F PPosition 5 226.3 45.3 3.146 0.0092Subjects 39 42169.3 1081.3 75.090 0.0000

Abbreviations: PS 1, 0° shoulder flexion with elbow fully extended; PS 2, 0° shoulder flexion with elbow flexed 90°; PS 3, 90°shoulder flexion with elbow flexed 90°; PS 4, 90° shoulder flexion with elbow fully extended; PS 5, 180° shoulder flexion with elbowflexed at 90°;PS 6,180° shoulder flexion with elbow fully extended.

153Prashant B Mukkannavar / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

and provides a quick reassessment of patient’s progressthroughout the treatment. The power grip is result of forcefulflexion of all finger joints with maximum voluntary force that thesubject is able to exert under normal bio-kinetic condition.7,15

The grip strength is affected by many conditions and somestudies had been designed to identify these factors. Musclestrength is the one of these factors. The synergistic action offlexor and extensor muscles and the interplay of the musclegroups is an important factor in the strength of the resultinggrip.7

This study has investigated the comparison of left and righthand grip strength in different positions of shoulder and elbow.From study, results revealed that significant difference found in00 shoulder flexion with elbow fully extended, 1800 shoulderflexion with elbow flexed at 900 and 1800 shoulder flexion withelbow fully extended (Table No. 2).This result is in accordancewith the study performed by Su et al.11 In his study grip strengthwas measured in four testing positions. The four hand strengthtests consisted three positions in which the elbow wasmaintained in full extension combined with varying degrees ofshoulder flexion (ie.00, 900, and 1800) and of one position inwhich elbow was flexed at 900 with shoulder in 00 flexion. Butthis study was done only in right-handed persons and as wellas test was conducted only in dominant hand.

From the study significant differences found in 00 shoulderflexion with elbow fully extended, 1800 shoulder flexion withelbow flexed at 900 and 1800 shoulder flexion with elbow fullyextended (Table No.2). On further analysis, these same positionswere found to be significant in right hand dominant subjects(Figure No.1,).The highest mean grip strength score wasobtained when the shoulder was flexed at 1800 with the elbowin fully extended. Grip strength decreased as the shoulder waspositioned in 00flexion and 900flexion (Table No.2). Thesefindings indicated that shoulder joint angle does affect gripstrength performance. In one study Bheem et al reported onthe effect of upper extremity posture on maximum grip strengthrevealed, that shoulder joint angle has an influence on gripstrength performance. 16It may be speculated that the synergisticmuscles of the back and shoulder may be able to act to theirbest advantage, when the shoulder is elevated at 1800shoulderflexion during grip. This overhead position appears to allow thoseproximal muscles involved to be stretched beyond their normalresting length, which would theoretically increase their efficiencyfor optimum exertion according to the principle of length tensionrelations. 17,18

In our study lowest mean grip strength score was recordedwhen shoulder was in 1800 flexion and elbow was flexed at 900

and highest mean grip strength score was recorded in1800shoulder flexion with elbow fully extended. This effect canbe explained by length tension-property of muscle contraction.This pattern could produce if shortening the fibers elbow flexorsdecreased their maximum force potential and/or lengtheningthe elbow extensors increased their maximum potential.

For all subjects no significant difference found in gripstrength measurement between 900shoulder flexion with elbowflexed at 900 and 900shoulder flexion with elbow fully extended(Table No.2). The most likely explanation for this that for bothshoulder positions an almost equal amount of synergisticactivities took place in the back and shoulder muscles. Proof ofthis requires further electromyographic studies to investigatemuscle activities of the upper extremity and back with regard totheir integrated functions during grip in these six combined elbowand shoulder positions.

An unexpected finding was that there was no significantdifference in left and right grip strength measurement during00shoulder flexion with elbow flexed at 900 in (Table No. 2).Further studies are required to explore this phenomenon. In ourstudy measuring grip strength with elbow joint at 900 flexion issignificantly different from measuring it in full extension. Sincegrip strength was measured in combination of shoulder and

elbow positions. Highest mean grip strength of left and righthand was recorded 1800shoulder flexion with elbow fullyextended. Grip strength with the elbow extension regardless ofshoulder was significantly higher than the elbow flexion position.It may be attributed to the fact that the length-tension relationshipof the forearm muscles involved in producing grip strength ismost favorable when the elbow in a position of extension.11,18

This result in accordance with the study performed by Su et al11.Previous studies have established that there is a

relationship between handgrip strength with elbow in fullextension.9,19 From the study 00 shoulder flexion with elbow fullyextended position, showed significant difference in grip strength(Table No.2). But this result is in contrast to the standardizedtesting protocol.6 In standardized testing protocol in which thesubjects’ shoulder adducted and neutrally rotated, the elbowflexed at 900, and the forearm and wrist in neutral position. Thesekind of alternative positions from standardized positions areuseful in identifying positions which maximize biomechanicalabilities and may assist in the design of environments and tools.7

Our study was limited to symptomatic subjects as well asambidextrous people. The use of convenience sample limitsthe generalization of the results of this study to the populationat large. In our study majority of subjects were right-handed.These norms should be used with caution for left handedpersons. During testing, we did not strictly control wristmovement, but it was found that all subjects naturally held theirwrists in certain degrees of extension when asked to give theirmaximal effort. Future studies are recommended on symptomaticindividuals and even to look at the results of grip strength onelbow position in combination with shoulder angle separately.

Conclusion

The changes in left and right hand grip strength observedwith variations in shoulder and elbow position. Grip strengthimproved with the increasing flexion angle of shoulder joint. It isvital that when measuring grip strength, one understands howsmall changes in body position can result in altered gripstrengths. Hence the findings are valuable in the evaluation andrehabilitation training of hand injured athletes or patients.

Acknowledgement

The authors sincerely thank to all the subjects whoparticipated in our study.

References

1. Nwuga VC. Grip strength and grip endurance in physicaltherapy students. Archives of Physical Medicine andRehabilitation. 1975; 56:296-9.

2. Mayers DB, Grennan DM, Palmar DG, Hand Grip functionin patients with rheumatoid arthritis: Arch Phys Med Rehabil.1982; 61: 369-72.

3. Myers CR, Golding LA, Sinning WE. The Y’s way to Physicalfitness. 1st Ed. Emmans Pennsylvania: Rodale Press Inc.1973: 49-50.

4. Rice CL, Cunningham DA, Paterson DH, Rechnitzer PA.Strength in an elderly population. Archieves of PhysicalMedicine and Rehabilitation. 1989:70:391-396.

5. Fraser C, Benten J. A Study of adult hand strength. BritishJournal of Occupational Therapy. 1983; 10:296-9.

6. Fess EE, Moran C. Clinical AssessmentRecommendations. Indianapolis: American Society of HandTherapists Monograph; 1981.

7. Richards LG, Okon B, Palmiter – Thomas P. How forearmposition affects grip strength. American Journal ofOccupational Therapy. 1996; 50: 133-138.

8. Amosun SL, Moyo A, Matara C. Trends in hand grip strengthin some adult male Zimbabweans. British Journal ofOccupational Therapy.1995; 58: 345-348.

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9. Balogun JA, Akomdafe CT, Amusa Lo. Grip Strength: Effectsof testing posture and elbow position. Arch. Phys MedRehabil. 1991; 72: 280-283.

10. Teraoka T. Studies on the peculiarity of grip strength inrelation to body positions and aging. Kobe Journal ofMedical Science. 1979; 25: 4-17.

11. Su CY, Lin JH, Chien TH, Cheng KE, Sung YT. Grip strengthin different position of elbow and shoulder. Archives ofPhysical Medicine and Rehabilitation .1994; vol. 75: 812-815.

12. Mathiowetz V, Renells C, Donahoe L. Effect of elbowposition on grip and key pinch strength. Journal of HandSurgery.1985; 10A: 694-697.

13. Ruiz-Ruiz J, Jose LM, Gutierrez A, Castillo MJ. Hand SizeInfluences Optimal Grip Span In Women But Not In Men.The journal of hand surgery. 2002; 27a: 897-901.

14. Desrosiers J, Bravo G, Hebert R, Dutil E. Normative Datafor Grip Strength Of Elderly Men and Women. The Americanjournal of Occupational Therapy.1995; 49 (1): 637-644.


15. Bohannon RW. Reference values for extremity musclestrength obtained by hand-held dynamometer from adultsaged 20 to 79 years. Arch Phys Med Rehabil. 1997; 78:26-32.

16. Kattel BP, Fredericks TK, Fernandez JE, Lee DC. The effectof upper extremity posture on maximum grip strength.International Journal Of Industrial Ergonomics. 1996;18:423-429.

17. Carlstedt CA, Nordin M, Frankel VH, editors. Basicbiomechanics of the musculoskeletal system.2nd ed.Phyladelphia: Lea and Febiger.1989:258-61.

18. Lehmkuhl LD, Smith LK. Brunnstorms clinical kinesiology.4th

ed. St.Louis: Mosby.1985; 50-144.19. Kuzala EA, Vargo MC. The relationship between elbow

position and grip strength. Am J Ocuup Ther. 1992; 46:509-12.

155

Correlation Between the Counting Talk Test and Body Mass Indexin Young AdultsPreeti Chauhan1, Pinki Bhasin2

1Final year student, Department of Physiotherapy, College of Applied Education and Health Sciences, Gangotri Colony, RoorkeeRoad, Meerut, Pin code: 25001, 2Lecturer, Srinivas College of Physiotherapy, Mangalore

Preeti Chauhan / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Background

Talk test has been used as a method of exercise prescriptionin a variety of populations. This is an easy informal guidelinewhich suggests that if the exercise intensity is sufficient so thatthe patient can “just respond to conversation,” then the exerciseintensity may within accepted ranges of exercise trainingintensity. Body mass index is used to classify a person as healthyor unhealthy. It is the commonly used measure of obesity. Thestudy attempted to correlate the counting talk test and the bodymass index.

Method

BMI value was determined from the height and weight. Thesubjects were made to perform a counting talk test at rest andduring treadmill walking. The total CTT scores and BMI wereanalyzed by Karl Pearson’s coefficient of correlation.

Result

No statistically significant correlation exists between thecounting talk test and body mass index.

Conclusion

Exercise prescription using the talk test can be done inindividuals with different categories of BMI. BMI will have noeffect on the counting talk test scores.

Key Words

Counting talk test, body mass index, exercise prescription,young adults.

Introduction

Many people are currently involved in cardio respiratoryfitness and resistance training programs and efforts to promoteparticipation in all forms of physical activity are being developedand implemented1.

Aerobic exercise is a decisively important component ofany fitness program. However, establishing and maintaining idealwork out intensities for the most effective and safe workoutscan prove to be a challenge for both exercisers and fitnessprofessional’s alike.2

Address for correspondence:Preeti ChauhanFinal year studentDepartment of Physiotherapy, A-122, College of AppliedEducation and Health Sciences, Gangotri Colony, RoorkeeRoad, Meerut, Pin code: 25001

There are well accepted guidelines for exercise prescription,both for healthy individuals and for patients with cardiovascularor other chronic diseases.1,3 These guidelines are generallyrelated to achieving well defined percentages of the peak heartrate (HR), peak oxygen consumption (VO2peak) or of the HR orVO2 reserve. Conformance with these guidelines maximizes thelikelihood that the healthy and fitness goals of exercise trainingwill be achieved while minimizing the risk of exertion relatedcomplication.4 Until now the rating of perceived exertion hasbeen the dominant tool for subjective monitoring of exercisetraining intensity.1,3

Another method advocated for prescribing an exercisetraining intensity is based on the talk test method or ability of anindividual to carry on a conversation during exercise;the counting talk test5.The rationale for this method is based onthe premise that exercising at or above the ventilatory thresholdgenerally does not allow to complete conversational sentenceswithout pausing for breaths and thus serves well as a means ofestimating the ceiling training intensity5. As a method of makingthe exercise prescription more simple, an informal guideline,widely referred to as the TALK TEST, has arisen within theexercise community.

The talk test is a simple and informal guideline whichsuggests that if the exercise intensity is sufficient so that thepatient can “just respond to conversation,” then the exerciseintensity may be “just about right” (i.e., within accepted rangesof exercise training intensity). Within the last several years, thevalidity of this simple guideline has been systematicallyevaluated. The ability to converse during exercise (i.e, to passthe Talk test) has been shown to produce exercise intensitiesconsistently within the parameters suggested in clinicalguidelines for exercise training in a variety of populationsincluding University students6, clinically stable patients withcardiovascular disease7 and athletes8. The talk test has beenshown to be well correlated with the ventilatory threshold, withaccepted guidelines for exercise prescription and with ischaemicthreshold2.

The main advantage of this method is its simplicity of use.Recently it has been shown that when using the talk test methodto estimate exercise intensity, individuals exercised at 85-88%of HRmax at the maximal point at which they could speakcomfortably or were equivocal in their response. When subjectscould no longer speak comfortably their exercise intensity wasgreater than the 90% HRmax limit advocated by the ACSM.6 Also,the talk test appears to be a simple practical, and yet fairly precisemethod of exercise prescription as it does not require preliminaryexercise testing or sophisticated monitoring strategies furtheradds to its appeal.

Obesity is defined by the World Health Organization (WHO)as BMI > 30kg/m2, and overweight is classified as BMI > 25kg/m2 .9

BMI is a ratio of a person’s weight to height. BMI iscommonly used to classified weight as “healthy” or“unhealthy.”BMI is a ratio of a person’s weight to height. BMIvalues between 18.5 and 24.9 are considered as “normal” or“healthy” weight. BMI values between 25 and 29.9 areconsidered “overweight” and above 29.9 are considered as“obese.” BMI above 25 are unhealthy and have been shown toincrease the risk of certain chronic diseases. BMI values under18.5 are considered as “underweight.”10-17

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Though, studies have been done on ‘Talk test’ and whichhave suggested it as a convenient method of exerciseprescription, but there is lack of knowledge about the correlationof the Talk Test with Body Mass Index. Hence, there arises aneed to conduct the study. The study aimed to uncover the“Correlation between the Counting Talk Test and Body MassIndex in young adults.”

Materials and Methods

Design of the study

Correlation study.

Sampling Design

Convenient sampling.

Apparatus used

1. Weighing machine.2. Height scale.3. Treadmill.

Outcome Measures

The given outcome measures were assessed1. Counting Talk Test score2. Body Mass Index

Procedure

A total of 30 young adults in the age group 19-24yrs wererecruited for the study, who were screened for inclusion andexclusion criteria. Informed consent was obtained from each ofthem prior to participation in the study. Demographic details wereobtained from each subject and the purpose of the study wasexplained. After the selection of subjects, according to theinclusion criteria, verbal instruction and demonstration was givenabout the testing procedure. BMI of each subject was calculated

as weight (kg) divided by height squared (m2) and categorizedusing WHO guidelines as

Lean <18.5kg/m2

Normal 18.5–24.9kg/m2

Overweight 25.0–29.9kg/m2

Obese e”30kg/m2

1. Assessment at Rest

At the beginning of the test, the given procedure wasperformed to record the CTT score of the subjects at rest.Subjects were asked to take in a full breath and count out loud,at their normal pace, using the following sequence: one-onethousand, two-one thousand, three-one thousand, etc. Thenumber the subject was able to count before having to take asecond breath was recorded. Only complete counts (eg. “Three-one thousand”) were used to record the highest number attainedbefore taking a second. Partial counts (eg. “Three-one” breath)were not included. The score was recorded as CTT score atrest.

2. Assessment during treadmill walking

Each of the subjects was then made to walk on the treadmillat a comfortable speed. The procedure described above for CTTwas repeated while the subject was walking on the treadmill ata comfortable speed. The treadmill walking was discontinuedwhen the subject complained of any unexpected symptoms suchas shortness of breathlessness, chest pain, leg fatigue, etc. TheCTT was repeated at the last 30 sec of every 2 min. untildiscontinuation of the treadmill walking. The total score wasrecorded as CTT score during the test.

The CTT score at rest, total CTT score obtained duringtreadmill walk and body mass index value of each subject wasrecorded and analyzed.

Findings and Result

Data was collected and then analyzed by Karl Pearsoncoefficient of correlation.

1. BODY MASS INDEX


Table 1: Body mass index.

The above table shows that the mean of BMI (N=30) is 21.54 and the standard deviation is 3.31.

2. COUNTING TALK TEST

Table 2: Comparison of Counting Talk Test scores at rest and during test.

The above table shows that mean of CTT rest (N=30) is13.10 and mean of CTT test with (N=30) is 86.43.The standard deviation ofCTT rest is 3.84 and that of CTT test is 45.14.

3. CORRELATION OF BODY MASS INDEXAND COUNTING TALK TEST

The above table shows that the Karl Pearson coefficient ofBMI and CTT rest is 0.114 and that of BMI and CTT test is 0.178.

‘p’ value of BMI and CTT rest is 0.550 and that of BMI and CTTtest is 0.347 both of which are non statistically significant.

The above data indicates that there exists no correlationbetween the BMI and CTT at rest as well as during the test.

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Table 3: Correlation of Body Mass Index and Counting Talk Test at rest and during test.


Scatter diagram 1: Comparison of BMI and CTT at rest.

It is clearly evident from the above scatter diagram thatduring rest, the total CTT score is between 10 and 15 with theBMI value ranging from 20.0 - 25.0 i.e, in the normal or healthyBMI category.

Scatter diagram 2- Comparison of BMI and CTT during thetest.

It is clear from the diagram that during the treadmill walking thetotal CTT score ranged from 50 to 100.

Discussion

A total of 30 young adults in the age group of 19- 24 yearswere recruited for the study. The study aimed at finding out thatwhether be present, a correlation between the counting talk test

and body mass index in young adults. It is evident from theliterature that the talk test can be used as a method forestablishing the exercise intensity and can be used as a suitablemeans of exercise prescription. Our study is a novel effort; noprevious studies have attempted to correlate the talk test andbody mass index.

In our study the BMI ranged from 17.1-18.3 (N=5) to 25.2-31.2 (N=3). The sample size was small (N=30) and the numberof adults in the lowest range (17.1-18.3) of BMI i.e, was only 5.In the range of BMI 25.2- 31.2 the number of adults was only 3.The highest number of adults, N= 22 were in the 19-23.8 BMIrange i.e, “normal” or “healthy” weight.

The results of our study suggested that there is nostatistically significant correlation between the Talk test and theBMI and hence it can be stated that exercise prescription canbe done in people with different ranges of BMI, by means of thetalk test. The BMI values will not affect the scores of the talktest. A question arises here, that it is known that obesity producesa restrictive lung disorder. The lung volumes and capacities, aswell as the excursion of the diaphragm is affected by the degreeof abdominal fat. Breathing pattern is rapid and shallow in obeseindividuals. All of this could, thus possibly have an impact onthe talk test scores due to increased work of inspiration in obesepersons. Additional studies on the topic, in adults with higherBMI values are required.

Another issue of concern is that age has an impact on thepulmonary function and the exercise capacity which may affectthe talk test scores. In our study young adults participated, furtherstudies should be done on older individuals as it is recognizedfact that respiratory mechanics and function worsens after 50years of age. Also, all the adults recruited for the study werenon smokers. Smoking deteriorates the lung function and hencemight indirectly affect the scores of the talk test. Upcomingstudies should address the above mentioned observations.

There were certain limitations of the study. The study wasdone on adults in the age group of 19-24 years and with differentBMI categories. The sample size was small (N=30) and most ofthe young adults were in the normal range of BMI i.e, 19-23.8.Further studies should be done in a particular age group of adultsand with extensive inclusion of adults with different categoriesof BMI.

Conclusion

The study concluded that there is no significant correlationbetween the talk test and body mass index. The body massindex will have no effect on the talk test scores.

Acknowledgement

We thank our subjects who participated in the study.

Conflict of Interest

The authors declare no conflict of interest.

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References

1. Pollock, M L, G A Gaesser, JD Butcher Despres, R KDishman and B A Franklin. The recommended quality andquantity and flexiblity in healthy adults. Med Sci sportsexercise 1998; 30: 975-991.

2. Persinger, R Foster, C Fater, D C W& Porcoari, J P.Consistency of the talk test for exercise prescription.Medicine and science sports and exercise 2004; 36(9):1632-1636.

3. Lippincott, Williams and Wilkins. ACSM’s. Guidelines forexercise testing and prescription. American college of sportsmedicine. 6th ed. Philadelphia 2000:137-234.

4. Foster C. and J P Poricari. The risk of exercise training. Jcardiopulmonary Rehabilitation 2001; 21: 347-352.

5. Baltimore MD: Williams and Wilkins. Resource manual forguidelines for exercise testing and prescription. Americancollege of sports medicine,1998.

6. Dehart-Beverley M, C Foster, JP Porcari, DCW Fater, RPMikat. Relationship between the talk test and the ventilatorythreshold. Clin Exerc Physiol 2000; 2:34-38.

7. Voelker SA, C Foster, KM Skemp-Arlt, G Brice, R Backes.Relationship between the talk test and ventilatory threshold.Clin Exerc Physiol 2002; 4:120-123.

8. Recalde PT, C Foster, KM Skempt-Arlt, et al. The talk testas a simple marker of ventilatory threshold. S AFr J Sportsmed 2002; 8: 5-8.

9. WHO. Obesity: Preventing and Managing the GlobalEpidemic. Geneva, Switzerland: 2000.

10. Spadano MA, Coakley EH, Field AE, Colditz G, Dietz WH.The disease burden associated with over weight andobesity. J Am Med Assoc 1999; 282(16):1523-1529.

11. NIH/NIDDK (National institutes of Health, National instituteof Diabetes and Digestive and Kidney Diseases), Nationaltask Force on Prevention and Treatment of Obesity. Obesityand Health Risk. Arch Intern Med (in press).

12. NIH/NHLBI (National Institute of Health, National Heart,Lung and Blood institute). Clinical guidelines on theIdentification, Evaluation and Treatment of Overweight andObesity in Adults. U.S. Department of Health and HumanServices, Public Health Service, 1998.

13. Hubert HB, Feinleib M., McNamara PM, Castelli WP.Obesity as an independent risk factor for cardiovasculardisease: A 26 year followup of participants in theFramingham Heart Study: Circulation 1983; 67: 968-977.

14. Walker SP, Rimm EB, Ascherio A, Kawachi I, Stampfer MJ,Willett WC. Body size and fat distribution as predictors ofstroke among US men. Am J Epidemiol 1996; 144: 1143-1150.

15. Colditz GA, Willet WC, Rotnitzky A, Manson JE. Weightgain as a risk factor for clinical diabetes Mellitus in women.Ann Intern Med 1995; 122: 481-486.

16. Giocannucci E,Ascherio A, Rimm EB, Colditz GA, StampferMJ, Willet WC. Physical activity, obesity, and risk for coloncancer and Adenoma in men. Ann Intern Med 1995; 122:327-334.

17. Hochberg MC, Lethbridge – Cejku M, Scott WW Jr, ReichleR, Plato CC, Tobin JD. The association of body weight,body fatness and body fatness and body fat distributionwith osteoarthritis of the knee: data from the BaltimoreLongitudinal Study of Aging. J Rheumatol 1995; 22: 488-493.


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Comparsion of the Depressive Symptoms and PhysicalPerformance in Mothers of Disabled and Non-disabled ChildrenRasmi Muammer1, Kiymet Muammer2, Yasemin C Yildirim3,Osman Hayran4

1Assistant Prof, Yeditepe University, Faculty of Health Sciences, Department of Physiotherapy, 2Istanbul University, CardiologyInstitute, Department of Physiotherapy and Rehabilitation, 3Psychologist, Kýzýl Irmak Rehabilitation Centre, Istanbul, 4Prof Dr, Deanof Faculty of Health Sciences, Yeditepe University, Turkey

Rasmi Muammer / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

The aim of this study was to investigate the depressivesymptoms and physical performance in mothers of disabled andnon-disabled children. The study and control populationconsisted of 40 mothers ( study group: n=20, mean age 38.35 ±6.76 years, and mean body mass index (BMI) 27.72 ± 3.97-control group: n=20, mean age 38.70 ± 7.64 years, and meanbody mass index 25.95 ± 4.25 ). Depressive symptoms wereevaluated using the Beck Depression Inventory (BDI). Physicalperformance was evaluated with the use of the Fifty-Foot Walk(FWS), the Sit to Stand (STS) and the Bend Forward Test (BFT).Mean Beck depression score was significantly higher amongcases than controls (p<0.001) and mean scores of threeparameters of physical performance tests were also significantlyhigher among cases than controls. (p<0.001). The resultsshowed that the mothers of disabled children have lower physicalperformance and higher depressive symptoms than mothers ofnon-disabled children.

Key Words

Retarded Child, Parents, Physical Performance,Depressive Symptoms.

Introduction

Parents and siblings of retarded children individually, aswell as the family as a whole, are at-risk of numerous difficultiessuch as depression, stress and anxiety in comparison to familieswith non-retarded children (Veisson, Marika,1999; Crnic et al.,1983). Numerous studies have been performed to investigatethe effects of retarded children on their families such as maritaland family strength and parental personality characteristics(Andersson, 1993). Findings Indicated significantly greaterstress in the families with handicapped children (Dyson etal.,1986) as well as association had been found betweendepressive symptoms and physical performance. Rose et al.,2005; Chen et al. (1992) studied the personality andcharacteristics of parents of children with learning disabilitiesand attention deficit disorder with hyperactivity and they foundthat mothers of learning disabled children and attention deficitdisorder with hyperactivity had higher hypochondriasis,depression, problems with assuming social responsibilities,dependency, anxiety, intervention, dominance, and/or neurotic-like personality disorders. Some previous research presentscertain conflicting results. On contrary to the studies which foundthat mothers of disabled children were more depressed thancontrol mothers, others revealed that there was no significantdifference between the parents of disabled children and controlgroups (Veisson, Marika,1999). Andersson (1993) demonstratedthat there were no differences between the mean values forparents of mentally retarded and nondisabled children, neitherconcerning anxiety nor depression. According to Abbott et al.,(1986) Parents with retarded children were less critical of familymembers, and they had fewer persistent family problems.

Feelings of anxiety and depression were analyzed in agroup of 13 mothers of children with Down syndrome. Thirteen

women without handicapped children served as a comparativegroup. The results were also compared with results obtained in18 mothers of motor handicapped children and 18 mothers ofchildren with mental retardation and psychotic symptoms. Mooddisturbances such as anxiety and depression seemed to beuncommon in the mothers of primary school children with Downsyndrome. Their experience of social support was not negativealthough the need for more empathy was expressed by someof them. There were no major differences between the mothersof children with Down syndrome and the mothers of motorhandicapped children. The results indicate that mothers ofchildren with Down syndrome fare better than mothers of childrenwith mental retardation and psychotic symptoms (Brandt, 1991).Additionally Depression has been linked to poor health outcomein a number of studies (Wing, 2002). Depressive symptoms maycontribute to a lack of motivation or effort which in turn results inless activity (Geisser et al., 2003). Depression leads to illnessand physical decline, either because of behavioral factors orbiological factors (Penninx et al.,2000). In this study, weinvestigated the relationship between depressive symptoms andphysical performance in mothers who have physically or mentallyretarded children and the others who have normally children.

Materials and Methods

Subjects

Forty women participated in this study. The study group(n=20, mean age 38.35 ± 6.76 years, and mean BMI 27.72 ±3.97) consisted of the mothers who have physically or/andmentally retarded children. The mothers provide regularlycontinuous attention and care of their children by making contactwith a special education and rehabilitation center twice a week.The control group (n=20, mean age 38.70 ± 7.64 years, andmean BMI 25.95 ± 4.25) included the mothers who have healthychildren. Subjects were excluded from the study if they hadsevere neurological, metabolic, cardiovascular, mental orpsychiatric diseases, motor and sensory dysfunction, pain orpregnancy. Depressive symptoms and physical performancetests were performed by a psychologist and physiotherapist. Allsubjects gave their informed consent for participating to the study.

Emotional Status

Depressive symptoms were evaluated using the BeckDepression Inventory-Turkish version (BDI) a well-validatedmeasure (Hisli, 1988) which is a self-report measure of cognitive,affective and neurovegetative symptoms of depression. It iscomposed of 21 statements about how respondents might havebeen feeling during the past week. The BDI statements wereranked from 0 to 3, with 0 representing least serious and 3 themost serious symptoms. The cutoffs are used are 0-13: minimaldepression; 14-19: mild depression; 20-28: moderatedepression; and 29-63: severe depression (Sagmanli et al.,2009).

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Physical Performance Tests

Walking velocity

The Fifty-Foot Walk Test (FWS) is a measure of gait velocityand function (Grace et al.,1988). Subjects were instructed towalk the 25 feet distance and turn back as fast as theycomfortable could without an assistive device. Time wasmeasured by chronometer (Silva et al., 2008; Sagmanli et al.,2009).

Balance Ability

The Sit-to Stand (or chair rise) Test (STS) is commonlyused to assess lower extremity strength and balance (Lord et.al.,2002). We used five times of the STS while the subjects crossingtheir arms on their chest and sitting with their back against thechair. Subjects began while they were in the seated positionand ended in the seated position as quickly as possible (Holzberget al., 1996; Sagmanli et al., 2009). Time was measured bychronometer.

Muscle Endurance

This test requires the subject to bend forward and return tostanding 10 times as fast as possible. Time was measured bychronometer (Sagmanli et al., 2009).



Collected data were analyzed by SPSS program. Arithmeticmean and standard deviation were calculated for summarizingdescriptive data. Unpaired t test was used for comparisons ofmothers of the disabled children with the controls and associationbetween Beck Depression scores and physical performancetests were analyzed by Pearson’s correlation analysis. Statisticalsignificance was considered when p<0.05 for all tests ofsignificance.

Results

The personal characteristics of mothers of disabled childrenand controls are given in Table 1. There was no significantdifference between mean age, mean number of children andmean BMI of mothers of disabled children and controls (p>0.05).All of the women in both groups were married. Beck Depressiontest and physical performance test results of the women whohave a mentally or physically disabled child in comparison withwomen who do not have a disabled child are presented in Table2. As it is seen from the Table, mean Beck depression scorewas significantly higher among mothers of the disabled childrenthan controls (p<0.001). Mean scores ( duration of performingthe tests) of three parameters of physical performance (walkingvelocity, balance ability and muscle endurance) were alsosignificantly higher among mothers of the disabled children thancontrols (p<0.001). Positive and significant correlations betweenBeck Depression scores and physical performance tests has

Table 1: Personal characteristics of mothers of disabled children and controls

Mothers of disabled Controls (n=20) P valuechildren (n=20) Mean ± SDMean ± SD

Age (yrs) 38.35 ± 6.76 38.70 ± 7.64 p>0.05BMI (kgr/mt2) 27.72 ± 3.97 25.95 ± 4.25 p>0.05Number of children 2.40 ± 1.04 1.89 ± 0.99 p>0.05

Table 2: Beck depression score and physical performance test (duration of performing the tests) results in mothers of disabledchildren and controls

Mothers of disabled Controls Pvaluechildren (n=20) (n=20)Mean ± SD Mean ± SD

Beck 19.00 ± 11.44 7.40 ± 7.30 p<0.001Walking velocity 14.90 ± 2.07 10.85 ± 2.18 p<0.001Balance 14.50 ± 3.48 8.60 ± 2.43 p<0.001Endurance 24.70 ± 6.62 17.30 ± 4.97 p<0.001

Table 3 : Correlations between Beck Depression scores and physical performance tests (duration of performing the tests) (n=40)

Beck Depression ScorePhysical performance tests r pWalking velocity 0.618 <0.001Balance 0.534 <0.001Endurance 0.654 <0.001

been found among all subjects (<0.001) (table 3), indicating thathigh depression scores associated with low performance level.

Discussion

Parents in every society play complex roles in training andsocialization of their children. These responsibilities becomemore difficult, perplexing and arduous in the case of retardedchildren. The parents of a handicapped child face more problemsthan normal ones (Alam et al., 2005). Depression frequently isseen in parents with physically or mentally disabled child(Veisson, Marika, 1999; Crnic et al., 1983). Veisson, Marika

(1999) demonstrated that especially mothers of disabledchildren, have significantly more negative emotional states andalso significantly more depressive symptoms. Significantdifferences in depression symptoms between the disabled andcontrol parent group were found in most symptoms. Parents inthe control group were significantly more happy, glad, satisfied,proud, grateful, happy for their child, pleased and hopeful. Theresults of current study showed that depressive symptoms wassignificanly higher among mothers with disabled child thancontrol group. These result are parallel to those are found in theliterature. Mothers of disabled children are less likely to be inemployment than their peers, yet research shows that

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employment provides both material and social resources and isassociated with lower level of distress (Sloper,1999; Beresford,1995; Walker et al. 1989). Inadequate housing and transportare also associated with high levels of distress (Sloper,1999;Bradshaw, 1978). In this study all mothers of disabled childrenwere unemployed housewives and were prevented from workingoutside the home due to lack of provision of services to cater forthe child’s needs during working hours, and inflexibility of servicesystems such as hospital appoinments and school transport(Sloper,1999; Kagan, 1998). All mothers of the control groupwere working women. These factors may have played anadditional role in the high scores of BDI presented in the sudygroup.

When evaluating the physical performance results in bothgroup we found that recorded time of walking velocity, balanceability and muscle endurance tests were significantly higheramong mothers of disabled children than controls thus thephysical performance parameters in the control group better thanthose in the study group. We did not encounter studies evaluateddirectly the physical performance of the parents of disabledchildren in the literature but it is well known that poor physicalfunction itself is associated with higher levels of depressivesymptoms and worsening of symptoms over time. (Rose et al.2005). Depression is directly related to poor health outcomeand contributes to a lack of motivation or effort which in turnresults in less activity (Wing, 2002; Geisser et al., 2003; Penninxet al., 2000, 1998). It was demonstrated that there is reciprocalassociation between depression and disability (Turner, 1988;Graney,2000; Lenze et al., 2001; Ormel et al., 2002). Arelationship between depression and physical performance hasbeen found among the aged persons. Several studies (Penninxet al., 2000, 1998; Bruce et al., 1994) provided evidence thatolder persons who report depressive symptoms are at higherrisk of subsequent physical decline. These results suggest thatprevention or reduction of depressed mood could play a role inreducing functional decline in older persons. A similar relationshipwas found in this study between Beck Depression scores andphysical performance tests and high depression scorescorrelated with low walking velocity, balance, and endurancelevels. An important point we observed in our study that bodymass index in each group reflected overweight so precautionsmust be taken. As a conclusion the results showed that theparents who have retared children had low physical performanceand high depressive symptoms in relation to others who havehealthy children so we suggest that care must be taken to providepsychosocial support in addition to exercise program to increasethe physical performance of this population.

References

1. Abbott D. A., Meredith W.H., 1986. Strengths of Parentswith Retarded Children, Family Relations, Vol. 35, No. 3,pp. 371-375.

2. Dyson L. , Fewell R., 1986. Stress and Adaptation in Parentsof Young Handicapped and Nonhandicapped Children: AComparative Study, Journal of Early Intervention, Vol. 10,No. 1, 25-35.

3. Veisson, Marika, 1999. Depression Symptoms andEmotional States in Parents of Disabled and Non-DisabledChildren, Social Behavior and Personality: an internationaljournal, Volume 27, Number 1,pp. 87-97(11).

4. Turner R. J., Noh S., 1988. Physical Disability andDepression: A longitudinal Analysis. J Health Soc Behav1988;29:23–37.

5. Rose S. A., Skarupski K. A., Bienias J. L., Wilson R. S.,Denis A. Evans D. A., Leon C. F., 2005. Do DepressiveSymptoms Predict Declines in Physical Performance in anElderly, Biracial Population. Psychosomatic Medicine67:609-615.

6. Chen, S., Wang, Y, Liu, Q., Ji, J., Gu, B. & Jia, M., 1992. A

preliminary Assessment of the Personality of Parents ofLearning Disabled Children and Children with AttentionDeficit Disorder with Hyperkinesis. Chinese Mental HealthJournal, 6(6), 246-249.

8. Andersson E., 1993. Depression and Anxiety in Familieswith A mentally Handicapped Child. International Journalof Rehabilitation Research, 16(3), 165-169.

9. Brita Ryde-Brandt B. R., 1991. Now It Is Time for Your ChildTo Go To School, How Do You Feel? International Journalof Disability, Development and Education, Volume 38, Issue1, pages 45 – 58.

10. Crnic K. A., Friedrich, W. N., Greenberg, M. T., 1983.Adaptation of Families with Mentally Retarded Children: AModel of Stress, Coping, and Family Ecology. AmericanJournal of Mental Deficiency, 88(2), 125-138.

11. Wing R., 2002. The Role of Adherence in Mediating theRelationship Between Depression and Health Outcomes.Journal of Psychosomatic Research, Volume 53, Issue 4,Pages 877-881.

12. Geisser M. E., Robinson M. E., Miller Q. L., Bade, S. M.,2003. Psychosocial Factors and Functional CapacityEvaluation Among Persons with Chronic Pain, J OccupRehabil 13, pp. 259–276.

13. Penninx B.W., Deeg D. J., Eijk J.T., Guralnik B.A., 2000.Changes in Depression and Physical Decline in OlderAdults: A longitudinal Perspective, Journal of AffectiveDisorders Volume 61, Issues 1-2, 1 December 2000, Pages1-12

14. Hisli, N., 1988. Beck Depresyon Envanteri’nin GeçerliliðiÜzerine bir Çalýþma. Psikoloji Dergisi, 6: 118-122.

15. Sagmanli S., Yagci N., Cavlak U., and Cetun A.,2009.Relationship between Pain Intensity, DepressiveSymptoms, Disability Level and Physical Functioning inChronic Low Back Pain Turkish Patients: GenderDifferences, Journal of Medical Sciences Volume: 9, Issue:6,Page No.: 257-263

16. Grace, E.M., E.M. Gerecz, Y.B. Kaassam, H.M. Buchanan,W.W. Buchanan and P.S. Tugwell, 1988. 50-foot walkingtime: A critical Assessment of an Outcome Measure inClinical Therapeutic Trials of Antirheumatic Drugs. Br. J.Rheumatol., 27: 372-374.

17. Silva, L.E., V. Valim, A.P.C. Pessanha, L.M. Oliveira, S.Myamoto, A. Jones and J. Natour, 2008. HydrotherapyVersus Conventional Land-Based Exercise for theManagement of Patients with Osteoarthritis of the Knee: Arandomized Clinical Trial. Phys. Ther., 88: 12-21.

18. Lord, S.R., S.M. Murray, K. Chapman, B. Munro and A.Tiedemann, 2002. Sit-to-stand Performance Depends onSensation, Speed, Balance, and Psychological Status inAddition to Strength in Older People. J. Gerontol. A. Biol.Sci. Med. Sci., 57: 539-543.

19. Holzberg, A.D., M.E. Robinson, M.E. Geisser and H.A.Gremillion, 1996. The Effects of Depression and ChronicPain on Psychosocial and Physical Functioning. Clin. J.Pain, 12: 118-125.

20. Graney MJ. The reciprocal relationship between disabilityand depression. J Am Geriatr Soc 2000;48:452–3.

21. Lenze EJ, Rogers J.C., Martire L.M., Mulsant B.H., RollmanB.L., Dew M.A., Schulz R., Reynolds C.F., 2001. III. TheAssociation of Late-Life Depression and Anxiety withPhysical Disability: A review of the Literature and Prospectusfor Future Research. Am J Geriatr Psychiatry; 9:113–35.

22. Ormel J., Rijsdijk F.V., Sullivan M., van Sonderen E.,Kempen G.I., 2002. Temporal and Reciprocal RelationshipBetween IADL/ADL Disability and Depressive Symptomsin Late Life. J Gerontol B Psychol Sci Soc Sci;57:338–47.

23. Alam A., Noureen H., Akhtar N., Imran M., Iqbal I., JamilM., 2005. Behavior of Parents Towards PhysicallyHandicapped Children J. Agri. Soc. Sci., Vol. 1, No. 1. 54-55.


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24. Penninx B.W.; Guralnik J.M., Ferrucci L., Simonsick E.M.,Deeg d.J., Wallace R.B., 1998. Depressive Symptoms andPhysical Decline in Community-Dwelling Older PersonsJAMA, 279:1720-1726.

25. Bruce M.L., Seeman T.E., Merrill S., Blazer D.G., 1994.The impact of depressive symptomatology on physicaldisability: MacArthur Studies of Successful Aging. AmericanJournal of Public Health, Vol. 84, Issue 11 1796-1799 1994

26. Sloper P.,1999. Models of Service Support for Parents ofDisabled Children. What Do We Know? What Do We Needto Know? Child Care Health Dev. Mar; 25(2):85-99

27. Beresford b., 1995. Expert Opinions: A survey of PrentsCaring for A severely Disabled Child, Policy Press, Birstol

28. Walker L.S., Ortiz-Valdez J.A., Newbrough J.R., 1989. TheRole of Maternal Employment and Depression in thePsychological Adjustment of Chronically Ill, MentallyRetarded and Well Children, Journal of PediatricPsychology, 14, 357-370

29. Bradshaw J., Lawton D., 1978.Tracing the Causes of Stressin Families with Handicapped Children British J. of SocialWork, 8/2, 181-192

30. Kagan C., Lewis S., Heaton P., 1998. Caring to Work:Accounts of Working Parents of Disabled Children, FamilyPolicy Studies Centre, Lond.

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Assessment of Maximal Inspiratory Mouth Pressure in HealthyIndividuals of Different Age Group: Normal ValuesRavi Savadatti1, Gajanan S Gaude1, Prashant Mukkannavar2

1Department of Respiratory Medicine, J.N.Medical College, Belgaum (Karnataka), 2S.D.M.College of Physiotherapy, ManjushreeNagar, Sattur, Dharwad (Karnataka)

Abstract

Background

The strength of the inspiratory muscle is measured bymaximal insiratory pressure. In this study we analyzed the normalvalues of Maximal inspiratory mouth pressure in healthyparticipants of different age groups and either gender.

Subject and Methods

160 healthy individuals between the age group of 30 to 69years of either gender were taken for the study. Males andfemales participants were separated in groups and each groupwas divided into four sub groups of 20 individuals according toage (Subgroup:30-39 years, 40-49 years, 50-59 years and 60-69 years). Maximum inspiratory pressure was measured usinga mechanical pressure guage. The largest negative pressuresustained for 1 second on the pressure gauge was recorded.All participants were allowed to rest for about one minute, andthen repeated the maneuver 5 times.

Results

The normal mean MIP values in 30-39 age group of malesubjects was 125 cmH2O, in 40-49 age group it was 120 cmH2O,in 50-59 age group it was 110 cmH2O and in 60-69 age group itwas 93 cmH2O. Similarly the mean PI max value in 30-39 agegroup of female subjects was 85 cmH2O, in 40-49 age group itwas79 cmH2O, in 50-59 age group it was 75 cmH2O and in 60-69 age it was 71 cmH2O. MIP reduced with advancing age andmales had greater MIP values than compared tofemales(P<0.01).

Conclusion

The MIP values obtained in our literature can be used asbase line values to measure inspiratory muscle strength. MIP isgreater in males when compared to females and these valuesdecline in advancing age.

Key Words

Respiratory muscle strength, Maximal inspiratory pressureand reference values.

Introduction

One of the most commonly used assessment of respiratorymuscle strength is maximal inspiratory pressure (MIP) also called

Ravi Savadatti / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Address for correspondence:Ravi SavadattiAssistant ProfessorS.D.M.College of Physiotherapy,Manjushre nagar, Sattur, Dharwad (Karnataka),E.mail:[email protected]

as PI Max. The MIP provides information based solely onmaximal output of the inspiratory muscle.1

According to Cook CD et al and Byrd RB et al by IrwinScot2 et al stated that, the strength of the respiratory musclecontraction is directly related to the intrinsic muscle properties.The pressure generated with the respiratory system dependson the forces generated during muscle contraction and the elasticproperties of the lung and the chest wall. Thus respiratory musclestrength has been defined as the maximum or minimum pressuredeveloped within the respiratory system at a specific lungvolume. MIP is measured as the static pressure developed inthe mouth at a given lung volume. The subject breaths througha mouth piece attached to a pressure tap and a shutter.2

According to Farkas GA et al, Road. J et al and BraunNMT et al study, as cited by American Thoracic Society/European Respiratory Society(ATS/ERS) statement3 onrespiratory muscle testing of 2002, stated that ‘Maximal strengthin the skeletal muscles is the force developed under isometricconditions with a muscle at its optimal length. In generatingpressure during respiratory maneuver, muscle shortening orlengthening may occur with changes in force velocity and forcelength relationship.’

The ATS/ERS statement3, on the study done by De TroyerA et al stated that the ‘mechanical linkage of each individualrespiratory muscle within the chest wall and with other inspiratoryor expiratory muscles influences the net pressure produced.Thus, even though activation may be maximal, the pressureproduced is derived from a complex set of interactions withinand between muscles and the chest wall and its contents.Nevertheless, it is the pressure developed by the inspiratorymuscles that drives ventilation and, in spite of the manyassumptions, these measures can usefully reflect globalrespiratory muscle strength for clinical evaluation as well asphysiological studies. Thus, when respiratory muscle weaknessoccurs, the PI max can be more sensitive than the vital capacity(VC) because the relationship between VC and PI max iscurvilinear’ so that decrease in respiratory muscle strengthoccurs before decreases in lung volume can be identified.Subjects find it easier to maximize their inspiratory efforts at lowlung volumes and expiratory efforts at high volumes; therefore,by convention and to standardize measurement, MIP ismeasured at or close to residual volume(RV).3

Rounded ‘tube’ mouth pieces inserted in the mouth for MIPgenerally give the highest values and have been used for mostpublished reference data.4 Hence in our study we have used arounded mouth piece to measure MIP.

A variety of methods for subject selection and testprocedures have been used for the determination of normalvalues for maximal inspiratory pressure (MIP). The objectivesof this study were to utilize mechanical pressure gauge withcustom mouthpiece adaptor for the measurement of MIP in awell-characterized healthy group of men and women with a wideage range (20 to 69 yr).

Several studies have aimed at assessing the normal valuesin the past for interpretation of maximal inspiratory pressuremeasurement on healthy individuals. Considering thesenormative values, we need to know whether these values matchthe healthy Indian population. We are not aware of any previousresearch that has investigated and predicted normal values onIndian population of different age groups. Hence the purpose of

164 Ravi Savadatti / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

this study is to assess the normal values of maximal inspiratorymouth pressure in healthy individuals of different age groups.

Methodology

Subjects

A total of 160 healthy individual between the age group of30 and 69 years of either gender from Physiotherapy departmentof S.D.M.College of Medical Sciences and Hospital wereconveniently taken for the study as per their inclusion andexclusion criteria. They were separated into two groups: male(N=80) and females (N=80). Each group was divided into foursub groups of 20 individuals according to age. Subgroup:30-39years (Subgroup:30-39 years, 40-49 years, 50-59 years and60-69 years).

Inclusion/Exclusion criteria

Healthy individuals with normal Lung function values wereincluded for the study. Subjects showing FEV1 or FVC < 70% ofthe predicted values on pulmonary function testing or Largepressure swings in the thorax or abdomen (aneurism,uncontrolled hypertension, urinary incontinence) were excludedfrom the study. Subjects were excluded if they had history ofsmoking or any respiratory, cardiovascular, neuromuscular, ormusculoskeletal diseases. All the individuals with deformities ofshoulder girdle and upper quadrant were also excluded fromthe study. Participants with cognitive deficits and those who donot understand the maneuver procedures were not allowed toparticipate in the study. Individuals who had pulmonary infectionsin the previous six months were excluded from the study.

Procedure

Subjects willing to participate in the study were briefed aboutthe study and the investigation. After briefing their written consentwas taken. A routine method of physical examination wasperformed by the physician and those who were declaredphysically and medically fit were taken for the study. Additionalevaluation was done by the principle investigator to identifypossible alteration in the thoracic and abdominal region.

Prior to the measurement of maximal inspiratory pressure(MIP) and pulmonary function test, body height was determinedusing a stadiometer with the subject standing bare foot andwearing light cloths. Body weight was measured using a weighingmachine, the participant was asked to remove all his/herornaments, metals and coins and was then made to stand barefoot on the weighing machine.

The pulmonary function test was done using spirometer insitting positon, forced vital capacity (FVC) and forced expiredvolume in 1 sec ( FEV1) were considered for the study.

MIP was measured using a simple apparatus that consistsof a well fitting disposable cardboard mouth piece connected toa small plastic chamber, to which a mechanical pressure gaugeis connected through a rubber tube of 2mm diameter. A smallleak was done to the mouth piece that prevents closure of theglottis during inspiration. The subject was made to sit in uprightposition and demonstration of the correct maneuver was done.The subject was instructed to avoid collapsing the cheeks duringthe measurement of MIP. Then the subject was asked to exhaleslowly and completely (to Residual volume), a nose clip wasattached, seal lips firmly around the new mouthpiece (to preventair leak), and then “pull in hard, like you are trying to suck up athick milkshake.” The largest negative pressure sustained for 1second on the pressure gauge was recorded. The participantwas allowed to rest for about one minute, and then repeatedthe maneuver 5 times. The highest value recorded, was takenfor the study. The mechanical pressure gauge has minor tick

marks at 5cmH2O increments, so results were rounded to thenearest 5cmH2O. 5,6

Statistical analysis

Results

A total of 160 healthy participants with a mean age, height,weight and BMI as shown in table 1 and 2 completed the studyprotocol. No adverse effects or complications were observedduring the measurement of maximal inspiratory pressure. 20Males (n=20) and 20 Females (n=20) were recruited in eachage group.

Table 1: Mean of Age, Weight, Height and BMI in healthy maleparticipants

Table 1, Shows Mean and SD of male subjects with respect toage, height, weight and BMI of different age groups. In age groupof 30-39, BMI was found to be slightly higher than the othergroups.

Age Age Weight Height BMIGroup Mean Mean Mean Mean

(SD) (SD) (SD) (SD)

30-39 34.25(2.6) 74.8 1.66 27.21(1.9)(n=20) (4.2) (0.05)40-49 44.65(2.3) 71.7 1.657 26.10(1.1)(n=20) (5.3) (0.06)50-59 54.95(2.6) 74.7 1.674 26.62(1.1)(n=20) (6.2) (0.05)60-69 64.6(2.9) 74.3 1.66 26.80(1.1)(n=20) (5.9) (0.0)

Table 2: Mean of Age, Weight, Height and BMI in healthy femaleparticipants.

Table 2, Shows Mean and SD of female subjects with respectto age, height, weight and BMI of different age groups. In agegroup of 40-49, BMI was found to be slightly higher than theother groups

Age Age Weight Height BMIGroup Mean Mean Mean Mean

(SD) (SD) (SD) (SD)

30-39 35.1 ( 3.0) 69.1 1.67 24.75 ( 1.5)(n=20) (5.3) (0.03)40-49 44.8(3.0) 69.0 1.64 25.37(1.4)(n=20) (7.2) (0.08)50-59 54.95(2.9) 70.35 1.69 24.42(1.9)(n=20) (5.4) (0.06)60-69 65.1(2.3) 70.45 1.67 25.15(2.8)(n=20) (5.7) (0.05)

Table 3: Normal values of maximal inspiratory mouth pressuresustained for 1.0s (PI, max.1.0) measured at residual volume inmales among various age groups.

Age Min Max Mean Std. SE 95% groups MIP Dev. Confidence

intervals

30-39 100 145 125.0 11.5 2.59 119.58 130.42(n=20)40-49 90 145 120.75 14.6 3.27 113.91 127.59(n=20)50-59 90 135 110.7 13.2 2.95 104.57 116.93(n=20)60-69 75 135 93.50 17.8 3.99 85.15 101.85(n=20)

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The mean PI max value in 30-39 age group of male subjectswas 125 cmH2O (95% CI= 119 to 130 cmH2O), in 40-49 agegroup of male subjects was 120 cmH2O (95% CI= 113 to 127cmH2O), in 50-59 age group of male subjects was 110 cmH2O(95% CI= 104 to 116 cmH2O) and in 60-69 age group of malesubjects was 93 cmH2O (95% CI=85 to 101 cmH2O).


Table 4: Normal values of maximal inspiratory mouth pressuresustained for 1.0s (PI, max.1.0) measured at residual volumein females among various age groups

Age Min Max Mean Std. SE 95% groups MIP Dev. Confidence

intervals

30-39 70.0 95.0 85.00 8.74 1.95 80.91 89.09(n=20)40-49 60.0 95.0 79.75 11.29 2.53 74.46 85.04(n=20)50-59 60.0\ 90.0 75.00 8.43 1.88 71.05 78.95(n=20)60-69 60.0 95.0 71.75 8.93 2.00 67.57 75.93(n=20)

The mean PI max value in 30-39 age group of female subjectswas 85 cmH2O (95% CI= 80 to 89 cmH2O), in 40-49 age groupof female subjects was79 cmH2O (95% CI= 74 to 85 cmH2O), in50-59 age group of female subjects was 75 cmH2O (95% CI=71 to 78 cmH2O) and in 60-69 age group of female subjectswas 71 cmH2O (95% CI=67 to 75 cmH2O).

Table 5: Comparison of male and females with PI Max valuesin different age groups

Age Sex Mean(SD) t-value p-valuegroups (PI Max or MIP)

30-39 Male 125.00 (11.58) 12.3288 0.0000*Female 85.00 (8.73)

40-49 Male 120.75 (14.62) 9.9229 0.0000*Female 79.75 (11.29)

50-59 Male 110.75 (13.20) 10.2047 0.0000*Female 75.00 (8.42)

60-69 Male 93.50 (17.85) 4.8735 0.0000*Female 71.75 (8.92)

* Significant at 5% level (p<0.01)

Statical analysis was performed to know the difference ofMIP among male and female participants (Table 5). The MIPscores in males and females using independent ‘t’ test showeda highly significant difference (p=0.0000) in all age groups (Table7).The mean MIP values of males in all age groups was greaterwhen compared to females.

Discussion

Assessment of inspiratory muscle strength is done bymeasuring MIP. We assessed the maximal inspiratory mouthpressure in healthy individuals of different age groups. Themeasurement of the MIP is strongly dependent on the skill ofthe examiner and the motivation of the participant. We specificallychose healthy subject population of different age groups to derivenormal values of MIP in this population.

Since the pressure developed by the respiratory musclesdepends on their resting length and mechanical advantage, it isbound to be abnormal in patients with any disease that changesthe resting volume and shape of the rib cage and diaphragm.4

These values may help us to differentiate between the normaland abnormal values in pathological conditions of the respiratorysystem.

Assessment of respiratory muscle function is difficult andcomplicated. A routine examination involves knowing the

mechanics of chest wall movement. This is followed byinvestigations that include PFT’s, MIP and maximal expiratorypressure measurement (MEP).4 Invasive techniques or noninvasive costly devices are used to measure MIP or MEP. In ourstudy we have used a low cost mechanical pressure gauge tomeasure MIP.

Inspiratory efforts are easier to do at low lung volumes andhence a standardizes measurement of MIP is done at or closeto residual volume.3 In our a study the MIP was measured atresidual volume. In the present study, we measured MIP in agroup of healthy individuals of different age group in order todefine a range of normal values.

JE Cotes et al7 commented on the number of trials thatneed to be done while measuring MIP, he quoted that a themeasurement is the maximal sustained pressure for 1 sec andthe result is the maximal value from3 determination that agreeto within 20%. Robert J et al in their study, stated that smallnumber of trial to measuring MIP is more appropriate than manytrials as many trials are impractical or impossible for the patients.Hence, we used a maximum of three trials for measuring MIP inour study.8

The reported normal values of MIP are -80 to -100cmH2O.1

Donna Frown Filter et al statement9 comments on the referencevalues of normal MIP by various authors. According to Blackand Hyatt(1969) the normal values of MIP for males was 124±22,and 87±16 for females. Bruschi (1992) reported MIP values formen as 120±37 and females as 84±30.

Various mouth pressures between the studies are notdirectly comparable. Differences in the age distribution of eachstudy cohort, methods and equipment may explain theseobservations in a better manner. The MIP values obtained inour study were, however, almost similar to those of otherinvestigators. This applies particularly to the data of Black andHyatt. The MIP values obtained of men in our study wereapproximately similar to those of Rodrigo P Simoes10 et al study.In our study, the mean MIP values of the 30-39 years age groupamong males and females subjects were 125±11.58 and85±8.74 respectively, while the age group of 40-49 was havinga mean of 120.75±14.62 in males and females having79.75±11.29. The MIP in the age group of 50-59 years wasslightly reduced with males having 110.75±13.21 and femaleshaving75.00±8.43. These values reduced subsequently as theage increased. The values obtained for the age group 60-69years showed a drastic reduction of MIP with males having93.50±17.85 and females with 71.75± 8.93(Table3,4.). Our datasupports the fact that, the mean values of the MIP reduced withthe advancing age.

Comparison of normal MIP values in males and femaleswas done, our results showed that, there was highly significantdifference seen in both the genders. MIP was greater in malesthan in females (table 5). A study done by Charfi MR11 et alshowed a similar kind of results, they stated that MIP andmaximum expiratory pressure (MEP) is greater in males than infemales.

Certain limitation of the study must be considered. MIPvalues in older individuals above the age of 70 years were notderived in our study. There was no comparison of MIP valueswith age, height, weight and body mass index. In future, studiesshould emphasize on more samples to know the relationship ofage, height, weight and BMI with MIP values.

Conclusion

There is a strong relation between age and sex with MIP.As the age advances there is decrease in the MIP values andthe values of MIP is greater in males as compared to femalepopulation. The present reference can be used as normal valuesof MIP in different age group of Indian population provided themeasurement is done in the same fashion as that which is donein the study because different methodology may alter the normal

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values. Hence we suggest that the normal values from thisliterature should be used for comparison with caution.

Acknowledgment

The authors wish to thank Dr Praveen Chandra and DrJavali for their help.

References

1. Wilkins RL, Stoller JK, Craig SL. Egans fundamentals ofrespiratory care.8th ed. Philadelphia:Elsevierssciences;2003:922-1126.

2. Irwin S, Tecklin JS. Cardiopulmonary physical therapy Aguide to practice.4th ed. Missouri: Mosby Inc;2004:57-58.

3. American Thoracic Society/European Respiratory Society.ATS/ERS Statement on Respiratory Muscle Testing. Am JRespir Crit Care Med ;2002;166(4):518–624.

4. Evans AJ, Whitelaw AW. The assessment of maximalrespiratory mouth pressures in adults. Respiratory care2009;54 (10):1348-1359.

5. Sachs CM, Enright LP ,Hinckley Stukovsky KD, Rui Jiangand R Graham B, for the Multhi-Ethnic Study of


Atherosclerosis Lung Study. Performance of MaximalInspiratory Pressure Tests and Maximal InspiratoryPressure Reference Equations For 4 Race/Ethnic Groups.Respiratory Care 2009;54(10):1321-1328.

6. Wen AS, Woo MS, Keens TG. How many maneuvers arerequired to measure maximal respiratory pressureaccurately? Chest 1997; 111:802-807.

7. Cotes JE, Chinn DJ, Miller MR. Lung Function.6th ed.Massachuselts: Blackwell publ;2006:105-107.

8. Smyth JR, Chapman KR, Rebuck AS. Maximal inspiratoryand expiratory pressure in adolescents. Normalvalues.Chest 1984;86:568-572.

9. Frownfliter D, Dean E.Cardiovascular and PulmonaryPhysiotherapy, Evidence and practice.4th

ed.Missouri:Mosby Inc;2006:453-457.10. Simoes RP, Deus AP, Auad MA Dionisio J, Mazzonetto M,

Borghi-Silva A.Maximal respiratory pressure in healthy 20to 89 years old sedentary individuals of central Sao PauloState. Rev Bras Fisioter.2010;14(1):60-7.

11. Charfi MR, Matran R,Regnard J,Richard MO, ChampeauJ, Dallava J,LockhartA.Maximal ventilator pressure throughthe mouth in adults: normal values and explanatoryvariables. Rev Mal Respir.1991;8(4):36-74.

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Physiotherapy Management of Chronic Back Pain: SystematicLiterature ReviewAcharya Ranjeeta1, AL-Oraibi Saleh 2

1Lecturer, Dhulikhel Hospital, 2Associate professor, Head of Physiotherapy Department, Applied Medical Sciences College, HailUniversity, Saudi Arabia

Acharya Ranjeeta / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Background

Systematic reviews offer a concise summary of theevidence on treatment effectiveness and it provides guidanceto physiotherapists and other clinicians on evidence basedmanagement of chronic low back pain. The main objective ofthis review was to critically appraise systematic reviews ofconservative therapies for chronic low back pain.

Methods

Literature searches through various online database.Articles were reviewed by three blinded therapists using threeinclusion criteria: 1) chronic low back pain, 2) systematic review,and 3) Randomized Control trails published in English.

Results

The search strategy retrieved 300 titles and abstracts; 54met inclusion criteria. A review of the full text of these articlesexcluded an additional 41 articles. Only 13 articles fulfilled theoriginal inclusion criteria and included in this review.

Conclusions

The overall quality of the current systematic reviews wassatisfactory. Clinically, the implication is that physiotherapyincluding physical activities and exercises should berecommended for patients with chronic low back pain. Thisreview outcome will be beneficial to researchers in the field oforthopedics, clinicians and policy makers to provide best qualityservices for patients with chronic low back pain.

Key Words

Chronic Back Pain; Low Back Pain; Physical therapytechniques; “Systematic review, Back Pain”

Introduction

Chronic low back pain is a common musculoskeletaldisorder associated with disability in developed countries. 1

However, there is limited information about the physiotherapymanagement of chronic Low Back Pain (LBP) in developingcountrie. 2 To further improve the effectiveness of interventionsprovided to clients suffering from chronic LBP, physiotherapistshave sought for evidence to inform their practice so they couldprovide the best possible management for their patients.

Globally, management of back pain is lacking coherence;patients with LBP seek help from medical doctors and otherallied health providers. However, differences in the training,education and scope of practice have lead to heterogeneity inthe management of chronic LBP.2, 3 Health research in developingcountries is relatively new and there is lack of research outcomesin the field of rehabilitation including physiotherapy. Systematicreviews, which provide the most concise summaries of researchevidence, are an alternative. Additionally, a critical appraisal ofsystematic reviews is as important as appraising the individualtrials included in those reviews. 4

The main objective of this review was to critically appraisesystematic reviews of conservative therapies for chronic low backpain.

Methods

Randomized control studies(RCT) studies, dealing withadults (16–80 years of age) who have chronic LBP, equal to orgreater than 3 months duration ,studies involving anyphysiotherapy modalities for the treatment of chronic LBP andstudies published in English language were included . 5 Studiesdealing with mixed populations of acute/subacute/ chronic lowback pain, surgical and invasive interventions studies and studieswith radicular pain syndrome resulting from nerve rootcompression were excluded. Other studies looked at alternativetherapies such as Acupuncture, Osteopath technique were alsoexcluded.

Search strategy include, a computerized search of theelectronic databases MEDLINE, EMBASE, Psychinfo, and theCochrane Database of studies were electronically searched fromJanuary 2000 up to December 2010 using the following terms:Review, literature review, back, chronic low back pain, spine,chronic pain.

The article selection process and its strategies wereadopted from other systematic LBP reviewers. 6 Review processconducted by three reviewers ,all reference lists in relevantreviews were screened, the search strategy was conducted bythe first author of this article (RA), and the results were given totwo reviewers (NS and SA). Each reviewer independently appliedthe selection criteria to the retrieved studies, and consensuswas used to solve disagreements.

Data Analysis

The following data were extracted by two independentreviewers (SB, and NS), databases and years searched, typeof patients, inclusion/exclusion criteria of trials in the study, typesof interventions, types of outcomes, design of studies andauthors’ conclusions and recommendations.

Results

The searches yielded 300 unique abstracts and articles.From these, 54 were retrieved for detailed reading. A review ofthe full text of these articles resulted in the exclusion of anadditional 41 articles. Only 13 articles fulfilled the originalinclusion criteria. Ten were published in 8 different peer-reviewedjournals and three in the Cochrane Library. Homogeneouspopulations were involved in the different studies regarding

Address for correspondence:Saleh AL-OraibiPhD, Associate professorHead of Physiotherapy Department, Applied medical SinceCollege, Hail University, KSAE-mail: [email protected]

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duration of low back pain which include patients with low backpain more than 3 months (chronic LBP). All reviewed trialsreported pain and function by using reliable and valid establishedstandardized tools. For example, Roland Morris Disabilityquestionnaires (RMDQ) 7,was applied in five studies ( 2,3,4, 5and 8); Visual Analogue Scale (VAS)8, was applied in threestudies. Only two studies included one measurement (2 and 7)while others included more than one measurement tools.


Type of Interventions

A total of seven separate types of interventions wereinvestigated in the 13 studies. To ensure the use of high qualityresearch, the research design of all reviewed articles wasRandomized controlled studies which consider the highestquality research design.

Studies Outcomes

Education and information (Table1):

In 678 patients with chronic LBP three studies (1- 3) lookedat the impact of providing information and education to reducepain and increase function. In two studies (2 and 3), the authorscompared education and information to physical activities whilein one study (1) it was compared to no active control.

Table 1: Summary of included trials related to information and education intervention. RCT: Randomized control study; RMDQ:Roland Morris Disability Questionnaires; VAS: Visual analogue Scale; N: number of population

Study Study Type Study N Age Outcome Main outcomes number year intervention design group(y) measure

(references)

1. Little, P, et al, 20017 Information RCT 310 16-80 Aberdeen pain a booklet was associated withand function reductions in a combined pain/Scale function score.

2. Smeets RJ, et al 20088 Education RCT 172 16-85 RMDQ During the one-year follow-up,there were no significantdifferences between eachsingle treatment and thecombination treatment on theprimary outcome.

3.Johnson, et al., 20079 Education RCT 196 18-65 RMDQ The intervention arm received a& VAS++ program of eight 2-hour group

exercise session over 6 weekscomprising active exercise andeducation delivered byphysiotherapists. Both armsreceived an educational bookletand audio-cassette.

Table 2: Summary of included trials related to physical activity and exercise intervention. RCT: Randomized control study; RMDQ:Roland Morris Disability Questionnaires; VAS: Visual analogue Scale; N: number of population

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Physical activity and exercise (Table 2)

In 2275 patients with chronic LBP, four studies (4-7)investigated the effect of physical activities and exercises toreduce pain and increase function. Most studies comparedphysical activities to other interventions. The physical activitiesand exercise group in these studies were consistently significant

better than control groups.

Manual therapy, soft tissue mobilization andstretching intervention (Table 3)

In 1607 patients with chronic LBP, three studies investigated

Table 3: Summary of included trials related to manual therapy, soft tissue mobilization and stretching intervention. RCT: Randomizedcontrol study; RMDQ: Roland Morris Disability Questionnaires; VAS: Visual analogue Scale; N: number of population

Study Study Type Study N Age Outcome Main outcomes number year intervention design group(y) measure

(references)

8. Little, P., et al, 2008 15 Manual therapy, RCT 579 18-65 RMDQ and Results showed significant massage and days in pain changes in the RMDQ score and back exercises days in pain for manual therapy

and back exercises compared to the control group and massage group.

9.Sherman K, et al, 200516 Yoga, therapeutic RCT 101 20-64 functionalstatus Yoga was more effective than a exercise or a (modified 24- self-care book for improving

self-care book point Roland function and reducing chronic Disability Scale) low back pain, and the benefits and “bother persisted for at leastt several someness” of months. pain (11-point numerical scale)

10.Calmels P, et al., 200417 Isokinetic RCT 17 16-75 VAS, trunk Isokinetic exercise is not better than mobility Schöber physiotherapy in reversing motor index, Biering inhibition in chronic low back pain -Sorensen and

Shirado-Ito test and Quebec

scale

the effect of some manual therapy intervention, soft tissuemobilization and stretching exercises compared to otherinterventions in terms of pain and function (8-10). Results showedthat: manual therapy and back exercises significantly betterthan the control group and massage group; Yoga was moreeffective than a self-care book for improving function andreducing pain and Isokinetic exercise is not better thanphysiotherapy in improving function.

Electrotherapy Therapy and Traction

In 427 patients with chronic LBP, three studies investigatedthe effect of electrotherapy modalities and traction to reducepain and improve function. There were minimal improvementsin chronic LBP patients following the use of traction. Regardingthe effects of electrotherapy modalities, TENS showedimprovement in all the outcomes measure compared with thecontrol group and there were significant effect of therapeuticultrasound compared to control group.

Discussion

For this chronic low back pain systematic review, 13 RCTswere found that compared physiotherapy interventions with acontrol group; the overall quality of the trials was high. Theoutcomes of this systematic review is very important to guidetherapists and medical professions who deal with patients of LBPwith the best available scientific evidence to be able to treatpatient safely and efficiently, especially in developing countrieswhere research activities and grant funds are very limited.

In this systemic review LBP interventions related to backpain education and information were investigated in three trials.9, 10, 11In all trials education and information using booklet or audio-cast showed reductions in pain and reduced of disabilities.However, when education compared to physical activities it wasno significant differences in pain and function. This indicate thateducation and information is important but physical activitiesplay even more important role in reducing LBP and improvefunction in adult patient with low back pain. This finding is in linewith other studies findings, that physical activity improve thefunctional ability and reduce pain of patients with chronic LBP.12

In terms of physical activity and exercises, this intervention wassignificantly better than control groups in terms of reducing painand increasing functional abilities of patients with LBP.13-15 Thesefindings were in agreement with other previous studies whichlooked at the impact of physical activities and exercises for mixedcondition of LBP .16

Regarding manual therapy, soft tissue mobilization andstretching interventions were significantly better than the controlgroup and massage group. 17Another interesting finding, thatstretching including Yoga was more effective than a self-carebook for improving function and reducing pain. 18 However, theeffectiveness of Yoga intervention may be different if the type ofcontrol group was different, in the current study the control groupwas provided with” inactive intervention” which include self carebook ,meaning unmonitored patient participation or limitedtherapist input. In another study(14), they found that interventionsfor back pain may lead to significant results if therapeutic


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exercises compared to inactive participation. As Yoga is part ofculture in many people around the world further randomizedcontrol studies are needed to compare Yoga with activetreatments such as therapeutic exercise.

In terms of electrotherapy therapy and traction, the resultshowed slight improvement for the use of traction in chronic LBP,19 and TENS showed improvement, 20 and there were significanteffect of therapeutic ultrasound compared to control group. 21

However, there are limited researches in this area and furtherresearch to look at the impact of traction and other electrotherapymodalities is recommended.

Conclusions

Clinically, physiotherapy including physical activities andexercises should be recommended for patients with chronic LBP.Other interventions such as Yoga, traction and electrotherapymay be recommended but requires further investigations beforetheir implementation in clinical practice.

References

1. Watson JD, Shay BL. Treatment of chronic low-back pain:a 1-year or greater follow-up. J Altern Complement Med2010 Sep; 16(9):951-8.

2. Haldeman S, Dagenais S. A supermarket approach to theevidence- informed management of chronic low back pain.Spine 2008; 8:1–7.

3. Koes BW, van Tulder MW, Ostelo R, Kim Burton A, WaddellG. Clinical guidelines for the management of low back painin primary care: an international comparison. Spine 2001;26: 2504–13.

4. Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L,Koes B, et al. A Critical Review of Reviews on the Treatmentof Chronic Low Back Pain. Spine 2001; 26(7): 155–162.

5. Tulder, MW van, Cherkin, D.C., Berman, B., Lao, L. KoesB.W. Acupuncture in the treatment of low back pain(Cochrane Review). IN The Cochrane Collaboration Library,Issue 1, 1999. Oxford: Update Software.

6. Engels EA, Schmid CH, Terrin N, Olkin I, Lau J.Heterogeneity and statistical significance in meta-analysis:an empirical study of 125 meta-analyses. Stat Med 2000;19: 1707–1728.

7. Roland MO, Morris RW. A study of the natural history ofback pain. Part 1: Development of a reliable and sensitivemeasure of disability in low back pain. Spine 1983; 8: 141-144.

8. Donald DP, Patricia AM, Amir R, Barbara B. The validationof visual analogue scales as ratio scale measures forchronic and experimental pain. Pain 1983;17: 45-56.

9. Little P, Roberts L, Blowers H, Garwood J, Cantrell T,Langridge J, et al. Should we give detailed advice andinformation booklets to patients with back pain? Arandomized controlled factorial trial of a self-managementbooklet and doctor advice to take exercise for backpain. Spine 2001; 26 (19):2065.

10. Smeets RJEM, Vlaeyen JWS, Hidding A, Kester ADM, vander Heijden GJMG, Knottnerus JA. Chronic low back pain:physical training, graded activity with problem solvingtraining, or both? The one-year post-treatment results of arandomized controlled trial. Pain 2008; 134(3):263.

11. Johnson RE, Jones GT, Wiles NJ, Chaddock C, Potter RG,Robert C et al. Active exercise, education, and cognitivebehavioral therapy for persistent disabling low back pain: arandomized controlled trial. Spine 2007; 32 (15):1578.

12. Hurwitz EL, Morgenstern H, Chiao C. Effects of recreationalphysical activity and back exercises on low back pain andpsychological distress: findings from the UCLA Low BackPain Study. AM J Public Health 2005; 95(10):1817-24.

13. UK Back pain exercise and manipulation (UKBEAM) TrialTeam. United Kingdom back pain exercise and manipulation(UK BEAM) randomized trial: effectiveness of physicaltreatments for back pain in primary care. BMJ 2004;329(7479):1377.

14. Kuukkanen T, Mälkiä E. Effects of a three-month therapeuticexercise programme on flexibility in subjects with low backpain. Physiotherapy Res Int 2000; 5 (1):46.

15. Maul I, Läubli T, Oliveri M, Krueger H. Long-term effects ofsupervised physical training in secondary prevention of lowback pain. Eur Spine J 2005; 14(6):599.

16. May S, and Johnson R. Stabilization exercises for low backpain: a systematic review. Physiotherapy.2008; 94: 179–189.

17. Little P, Lewith G, Webley F, Evans M , Beattie A, MiddletonK et al. Randomized controlled trial of Alexander techniquelessons, exercise, and massage (ATEAM) for chronic andrecurrent back pain. BMJ 2008; 337: a884.

18. Sherman KJ, Daniel C, Cherkin DC, Erro J, Miglioretti DL,Deyo RA . Comparing Yoga, Exercise, and a Self-Care Bookfor Chronic Low Back Pain. Ann Intern Med 2005; 143:849- 856.

19. Harte AA, Baxter GD, Gracey JH: The efficacy of tractionfor back pain: A systematic review of randomized controlledtrials. Arch Phys Med Rehabil 2003, 84:1542-1553.

20. Jarzem PF, Harvey EJ, Arcaro N, Kaczorowski J.Transcutaneous electrical nerve stimulatio(TENS) for short-term treatment of low back pain - Randomized double blindcrossover study o sham versus conventional TENS. JMusculoskelet Pain 2005;13(2):11

21. Ansari NN, Ebadi S, Talebian S, Naghdi S, Mazaheri H,Olyaei G, Jalaie S. A randomized, single blind placebocontrolled clinical trial on the effect of continuous ultrasoundon low back pain. Electromyography Cli Neuro physiol 2006; 46(6):329-36


171Shivani Chowdhury Salian / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

A Comparative Study to Ascertain Differences Between Rheobase,Girth and Isometric Strength Amongst Dominant and NonDominant Upper Limb in Normal SubjectsShivani Chowdhury Salian1, Sujata Yardi2, Vinita P. Kadam3

1Assoc Prof, 2Prof and Director, 3PT, Department of Physiotherapy, Dr. D.Y. Patil University, Nerul, Navi Mumbai, India

Introduction

In everyday life hand functions are integral and importantpart in all functional activities. In case of impaired hand functiondue to brain lesion, peripheral neuropathies and other cases itbecomes imperative that the hand strength, girth and rheobaseshould be evaluated in order to, determine the severity of handdysfunction and establish an effective rehabilitation program.

Grip strength is a useful tool for assessing a variety of sportand medical (clinical) situations. Grip strength can also be usedin clinical setting such as rehabilitation, to determine the extentof an injury or disease process and potential for and progressof the individual in rehabilitation 1. Ultimately it helps to establisha baseline or guideline for the treatment program and acts as ameasure to decide the therapy is effective 2 Studies that focuson the effect of handedness on grip strength can be beneficialin assisting coaches ,doctors and therapist determine howserious the injury or disease is as well as assisting them indesigning and monitoring the individuals progress inrehabilitation, On the other hand if it is known that there is nodifference between the grip strength in the dominant and nondominant hands then the therapist must come up with analternate way to find out what the individual’s original strengthof the hand was, as well alternate ways to measure the extentof the injury and the progress of rehabilitation .It is also beneficialto know if there is a difference in grip strength or general strengthof the dominant and non dominant hands so that we know whateach hand is capable of in everyday life situation.

Hence reliable and valid evaluations of hand is utmostimportant. It is useful for determining the effectivity of differenttreatment strategies .It is also widely accepted that grip strengthprovides an objective index of functional integrity of the upperextremity.

Recent studies have attempted to provide a definitivepicture of differences between the dominant and non-dominanthand strength. Crosby et al 3 invested normative values ofhandgrips and claimed that significant differences were foundbetween the dominant and non dominant hand .In the their studygrip strength was 6% higher for dominant hand.

There were controversies regarding the differences in thehand grip strength values between the dominant and nondominant hand in right and left handed people. So this studywas designed to evaluate the differences in the grip strengthbetween right and left-handed population.

The strength duration test was first used for the clinicalpurpose by Adrian (1916) 4, and later developed by Ritchie(1944) 5 .The classical galvanic –faradic test , first was usedabout 1859 by Bacerlacker (Licht,1961) 6 was considered byHickock in 1961 7 to be the most commonly used electro-diagnostic procedure. Today this test has been almostcompletely superseded by the strength duration test. Thestrength duration test is a method of testing electrical reactionsthat are simple and reliable and indicates the proportion ofdenervation, while a series of test shows changes in thecondition.

Rheobase is the threshold intensity for the pulse of infiniteduration (100 milliseconds or higher). Normal values varyconsiderably. Harris (1961) 8 gives a range of mean values from8 to 35 volts and Richardson 9 and Wynn Parry (1959) 10 givesfrom 15 to 30 volts. In denervation the rheobase may be less

than that of innervated muscle, and it often rises as re-innervations commences.These changes are not; however,sufficiently predictable to be reliable guides .The rheobasesvaries considerably in different muscles and according to skinresistance and temperature of the part, while a rise may be dueto fibrosis of the muscle. Thus the parameter of rheobase wasconsidered in the study to compare differences in the dominantand non-dominant hand muscles.

Girth measurements are taken to compare the girth ofdominant and non dominant hand at particular reference pointsthey are the proximal palmar crease, midcarpal and distal palmarcrease11.

Hence, the above mentioned three parameters –Isometricstrength, Rheobase and Girth were used to compare andascertain differences in dominant and non-dominant upperextremity.

Aim

• To compare and ascertain differences between theRheobase, Girth and strength in dominant and nondominant hand intrinsic muscles.

Objectives

• To assess the Rheobase of Adductor Pollicis, PalmarInterossei, Flexor Digitorum Profundus in Right and Lefthand.

• To assess the Girth as per reference points proximal palmarcrease, midcarpal and distal palmar crease.

• To evaluate the isometric strength of hand intrinsic musclesusing Jamar dynamometer.

• To compare the Rheobase, Girth and Isometric strength ofdominant and non dominant hand in normal subjects.

Methodology

Research Approach

Prospective

Sample Size

150 subjects.

Inclusion Criteria

Normal subjects in the age group of 18-25 years. Dominanthand was preferred for the activities of daily living.

Exclusion Criteria

• No participant reported ambidexterity• No restriction of upper limb movement.• No history of inflammatory disease.• No neurological disorder.• No history of trauma to upper extremity.

Duration: 6 months.

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Materials used

• Girth of hand –Measured with thread and measuring tape.• Isometric strength of hand – Jamar dynamometer.• Rheobase of hand intrinsic muscles and long flexor-

Diagnostic muscle stimulator, carbon electrodes, straps.

Shivani Chowdhury Salian / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Procedure

• Subjects personal information i.e. their name, age, sex anddominance was documented.

• Grip strength was measured using a standard adjustableJamar dynamometer. With shoulder adducted and neutrallyrotated, elbow in 90 degree flexion and wrist in slight ulnardeviation and extension12, 12.a Results were recorded inkilograms. All the measurements were performed for thedominant and non dominant hands. Subjects performed 3attempts and the average was recorded.

Measurement of Isometric Strength using Jamar Dynamometer

• Girth was measured using thread and measuring tape.Results were recorded in centimeters. The thread wasplaced on proximal carpal crease, midcarpal and distalpalmar crease. The thread was placed on measuring tapeto document the measurement.

• Rheobase of adductor pollicis, palmar interossei and flexordigitorum profundus is recorded using diagnostic musclestimulator, carbon electrode, pen electrode, water andstraps.

Girth measurementRheobase measurement

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Reference points for girth measurement

Diagnostic Stimulator with pen electrode and carbon electrode.

Results

1. There is no significant difference in the girth of dominantand non dominant hand with p values at proximal, middleand distal level are0.20, 0.22 and 0.82 respectively.

2. There is no significant difference in the rheobase ofdominant and non dominant hand with p values of musclesAdductor pollicis, Palmar interrossei and Flexor digitorumprofundus are 0.08, 0.7 and 0.1 respectively.

Girth in Dominant & p-value ConclusionNon Dominant hands

Proximal 0.20 Statisticallynon Significant

Middle 0.22 Statisticallynon Significant

Distal 0.82 Statisticallynon Significant

Girth Mean Standard Deviation

Dominant-Proximal 16.20 1.20Middle 20.59 1.50Distal 19.29 1.74Non Dominant-Proximal 16.25 1.31Middle 20.34 2.86Distal 19.24 1.68

Rheobase Mean Standard Deviation

Dominant-Adductor pollicis 11.62 2.48Palmar interrossei 12.19 3.04Flexor digitorum profundus 10.13 2.44Non Dominant-Adductor pollicis 11.19 3.10Palmar interossei 12.25 2.93Flexor digitorum profundus 10.35 2.69

Girth in Dominant & p-value ConclusionNon Dominant hands

Adductor pollicis 0.08 Statistically non Significant

Palmar interossei 0.7 Statistically non Significant

Flexor digitorum profundus 0.1 Statistically non Significant

3. There is a significant difference in the isometric strength ofdominant and non-dominant hand with a p value of 0.00.

Discussion

Firstly the study results show that there is no significantdifference in the girth of dominant and non-dominant hand.According to the statistics there is a minor difference in the girthof dominant and non dominant hand recorded at the threereference points that are at proximal palmar crease, midcarpallevel and distal palmar crease with p values of (0.2), (0.8), (0.08)


174 Shivani Chowdhury Salian / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Isometric strength Mean Standard Deviation

Dominant 21.23 6.37

Non Dominant 19.18 5.78

Isometric strength p-value Conclusion

Dominant and 0.00 Statistically Non Dominant Significanthand

which are not significant. Clinically the dominant hand tends tobe larger than the non-dominant hand 13. However the differenceis not large enough to interfere with hand rehabilitation.

Secondly the study shows that there is no significantdifference in the rheobase of the dominant and non-dominanthand, the rheobase value of each muscle is different irrespectiveof the dominance factor. The muscles considered were adductorpollicis, palmar interrossei and flexor digitorum profundus. Thep values are the adductor pollicis (0.75) palmar interrosei (0.75)and flexor digitorum profundus (0.12), which are not significant.The rheobase varies considerably in different muscles andaccording to skin resistance and temperature or the part, whilea rise may be due to fibrosis of the muscle. 14. This is evidentfrom the different rheobase values of the three muscles.Rheobase values are taken into consideration when a patientneeds to undergo treatment techniques involving interruptedgalvanic stimulation. Theoretically, rheobase value is taught tobe a prognostic measurement while undergoing treatment forany kind of nerve injury. Our finding about rheobase values notbeing different in dominant or non-dominant hand in normalsubjects, establishes the fact that rheobase values is a tool forjudging prognosis clinically in patients suffering any kind of nerveinjury. Therefore, rheobase values from contralateral to affectedhand can be effectively considered as a baseline parameterbefore starting hand rehabilitation.

Thirdly the study results showed significant differences inthe strength of dominant and non-dominant hand. The p valueis (0.001) which is highly significant. The power grip is the resultof forceful flexion of all fingers with the maximum voluntary forcethat the subject is able to exert under normal biokineticcondition15, 16. The synergistic action of flexor and extensormuscle and the interplay of muscle groups is an important factorin the strength of the resulting grip. 17 Many factors includingfatigue, hand dominance, time of the day, age, state of nutrition,pain, co-operation of patient and presence of amputation,restreicted range of motion, sensory loss can influence thestrength of the grip. A general rule often used suggests thatdominant hand is approximately 10% stronger than the non-dominant hand 16, 17. The 10% rule dates back to 1954 whenBectol observed that most patients presented a difference of5%to10% between the dominant and non dominant hand someprevious studies 17,1 8, 19 presented their data on hand dominanceas major/ minor hand or dominant / non dominant hand. Thisdifference of strength should be considered while a patient hasto go undergo hand rehabilitation for any type of nerve injury.Such a finding is therefore suggestive of amount of importanceto be laid down while evaluating strength of the affected handwith respect to its contralateral side. This enables us to establishthat comparison of isometric strength of muscles in handrehabilitation would not be an effective tool of prognosis as thebaseline strength of muscles in dominant & non-dominant handsare not equal in normal individuals.

Conclusion

• There is no significant difference between the values ofrheobase of the muscles adductor pollicis, palmar interossei

and flexor digitorum profundus of dominant and non-dominant hand.

• There is no significant difference between the values ofgirth as per the reference points proximal palmar crease,midcarpal and distal palmar crease of dominant and non-dominant hand.

• There is a highly significant difference between the valuesof isometric strength of hand intrinsic muscles assessedwith Jamar dynamometer in dominant and non-dominanthand.

Clinical Application

1. The contra lateral side can be used as reference fordetermining evaluative values as far as girth & rheobaseare concerned. The aspect of dominance would not interferewith traditional treatment parameters and the total phaseof treatment would be changed with the outcome beingvery effective.

2. Our finding about rheobase values not being different indominant or non-dominant hand in normal subjects,establishes the fact that rheobase values is a tool for judgingprognosis clinically in patients suffering any kind of nerveinjury. Therefore, rheobase values from contralateral handto affected hand can be effectively considered as a baselineparameter before starting hand rehabilitation.

3. Comparison of Isometric muscle strength of hand musclescannot be considered as baseline parameters for assessingprognosis of patient undergoing hand rehabilitation.

References

1. Richards’s et.al, 1991, Olson B Plamitter position affectsgrip strength, Am J occup ther 1996,50:133-9

2. Su, C. Y., Cheng, K. F., Chien, T. H., & Lin, Y. T. (1994).Performance of normal Chinese adults on grip

3. strength test: A preliminary study. Kao Hsing I Hsueh KoHsueh Tsa Chih, 10, 145-151.Crosby, C. A., & Wehbe, M.A. (1994). Hand strength: Normative values. Journal ofHand Surgery, 19A, 665-670

4. Adrian (1916) “the electrical Reaction of muscles beforeand after Injury”,Brain ,39:1

5. Ritchie (1944), “ electrical Diagnosis of the Peripheral Nerveinjuries “,Brain 39:1.

6. Bacerlacker (Licht,1961)7. Hickock in 1961,R.J (1961) “Physical Therapy as Related

to Peripheral nerve Lesions” ,Phys Ther Rev,41:113-11.8. Harris (1961), “Chronaxie” in electrodiagnosis and

electromyographic 2nd Edition.editedS.Licht.E.LichtConnecticut,ch,9.pp.218-240

9. Richardson ,AT(1950) in recent Advances in PhysicalMedicines Edited by F.Bach.J and A.Churchill Ltd.,London.

10. Wynn Parry:Rehabilitation offhand ,2nd editionLondon:Bullervoris 1966.

11. Juzo Measuring for Juzo® Compression Gauntlets12. Bechtal, C.D.:Grip Test: The Use of Dynamometer with

adjustable handle spacing. J.Bone JointSurgery.Am.36:820-832,195412.a Mathiowetz,V.,K.Weber,G.Volland, & N.Kashman:Reliability & validity of grip &pinch strength evaluatyions. J.Hand Surgery.Am.9:222-226,1984

13. David J.Magee, Orthopedic Physical assessment, Chap7. Forearm,Wrist & Hand pg-360, Saunders, 2002.

14. Angela Foster Nigel Palastanga, Clayton’s Electrotherapy.Chap-3, Electrical Stimulation of Nerve & Muscle pg-95AITBS Publishers 9th ed. 2004.

15. Richards L. Olson B Palmitter position affects grip strength,Am J occup ther 1996, 50:133-9.

16. Bohannon Rw, Ref values for extremity muscle strength

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obtained by hand held dynamometer from adults aged 20to 79 years, arch phys med rehab 1997, 78:26-32.

17. Lunde Bk .Brewer WD Garcia PA: Grip strength of collegewomen arch Phys Med Rehabilitation 53:491-493, 1972.

18. Swanson AB.Mater .Groof G de: strength of hand. BullProsthet Res BPR 10-14:145-153. Fall 1970

19. Thorgren K-G. Werner CO: N grip Strength: Acta OrthopScand 50:255-59 1979.


176

Physiological Quadriceps LagShweta Basu Roy1, Sona Kolke2

1Lecturer, Sancheti Institute, College of Physiotherapy, Pune, 2Principal, College of Physiotherapy, Vishwakarma Institute of HealthScience and Research, Pune, Maharashtra

Shweta Basu Roy / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Aim

To evaluate whether quadriceps lag exists in normal healthyindividuals.

Objective

1. To analyze if quadriceps lag exists in healthy adults2. To analyze if this quadriceps lag increases with a sustained

contraction of 5 seconds.3. To analyze the difference in quadriceps lag between males

and females.

Design

Repeated measures desig.n

Method

A study of active and passive limit of knee extension wascarried out on 48 healthy adults.With the subject seated for thepassive test the examiner lifted the heel until the relaxed kneesagged into full extension under its own weight. The active testcomponent comprised maximum active extension held for atleast5 seconds.Videotaped reference markers on the lateral aspectof the limb were computer analyzed to derive the active andpassive knee extension.

Result

The active limit of knee extension was less than the passivelimit by an average 5.04 degrees at the instant of maximumknee extension and by 6.34 degrees and 7.22 degrees at 3 and5 seconds respectively. At 0 and 5 seconds 45.7% and 72.9%of the subjects manifested a quadriceps lag of atleast 5 degrees.There is also no significant difference, in the quadriceps lagmanifested in males and females.

Introduction

The knee joint, composed of the distal femur, proximal tibiaand the patella, is stabilized and powerfully motored by musclesthat cross the joint from their origin above the hip joint and theshaft of the femur to insert upon bony structures below the kneejoint. These muscle groups are commonly classified asextensors, flexors, abductors and adductors.

Of the above mentioned muscles the extensors are ofgreatest importance to the stability of the knee joint. Thequadriceps femoris muscle represents the primary kneeextensors, although the Tensor Fascia Latae also contributesto knee extension. The quadriceps femoris is composed of 4heads :Rectus Femoris, Vastus Lateralis, Vastus Medialis andVastus Intermedius. These muscles along with the patella andpatellar tendon form the extensor mechanism in the knee. Thequadriceps muscle group functions as a knee extensor whenthe leg is elevated. When the foot is on the ground, contraction

of the quadriceps stabilizes the knee, functioning as adecelerator15.

Mechanically the efficiency of the quadriceps muscle isaffected by the patella, so much, so that the contribution to anincrease of extension strength made by the patella increaseswith progressive extension of the knee, being almost 30% at fullextension17.

The patella lengthens the moment arm of the quadriceps,increasing the distance of the quadriceps tendon and the patellartendon from the knee joint. The patella acts as an anatomicpulley, and deflects the action line of the quadriceps muscleaway from the joint, increasing the angle of pull and the abilityof the muscle to generate an extension torque. However asmentioned earlier, the contribution of the patella to improvingtorque production by the quadriceps, will vary with the joint rangeof motion.

Thus a 60% increase in quadriceps force over that neededin the rest of the range of motion, is required to complete thelast 15 deg. of knee extension.

The fact that the quadriceps as a whole has been seen toundergo reflex inhibition with any injury to the knee along morethan mild force with a 60% increase in quadriceps force requiredto complete the terminal range, explains why extension lag is acommon symptom with any kind of knee pathology.

And how exactly do we define muscle lag? Muscle lag isan inability to actively move a joint to its passive limit, where thepassive limit has been achieved without producing significantdiscomfort, and without exerting more than mild force againstresistance from joint stiffness or other soft tissue tightness. Theactive limit should be determined with the patient positioned sothat the moving segment is resisted by gravity, but no otherexternal load11.

The causes of quadriceps lag would be any injury to theextensor mechanism of the knee which is most commonly dueto a sudden or violent force. In older individuals it could be dueto a sudden increase in their activity level.

It is widely believed that lag is always abnormal. But doesquadriceps lag exist in healthy adults?

Active extension goes beyond the position ofreference(position in which axis of the leg is in line with the axisof the thigh)rarely, whereas it is possible to achieve passiveextension from this position, of 5 to 10degrees10. Fiber lengthhas a significant influence on the magnitude of joint motion thatresults from a muscle contraction.

Nicolas Babault et al carried out a study; “Effect ofquadriceps femoris muscle length on neural activation duringisometric and concentric contraction”, published in the “Journalof Applied Physiology”, in the year 2002, where they haveconcluded that muscle length has a predominant effect on neuralactivation that would modulate the angular velocitydependency18.

Keitaro Kubo et al. performed the study: “Activation ofagonist and antagonist muscles at different joint angles duringmaximal isometric efforts” published in the “European Journalof Applied Physiology” in the year 2004.

The purpose of this study was to investigate the influenceof different angles of the knee joint on the activation level of anagonist (quadriceps femoris muscle) and antagonist (bicepsfemoris muscle) from electromyographic activities and activationlevels (twitch interpolation).

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The activation levels at the knee-flexed position (80-110°)were higher than that at the knee-extended position (40-70°).The co-activation levels at 90, 100, and 110° were significantlyhigher than that the other knee angle. These results suggestthat the activation level of an agonist (quadriceps femoris) muscleand the co-activation level of an antagonist (biceps femoris)muscle were higher in longer muscles than in shorter muscles11.

Each sarcomere can shorten to approximately the lengthof its myosin molecules. Because the sarcomeres are arrangedin series in myofibril, the amount of shortening that a myofibriland ultimately a muscle fiber can produce is the sum ofshortening in all of the sarcomeres. A fiber can roughly shortento 50% to 60% of its length. Likewise an isometrically contractingmuscle is weaker when it progressively contracts at shorterlengths19. This normal phenomenon termed as “ActiveInsufficiency” is due to a diminished capacity of shortened muscleto develop actin-myosin cross bridges(Lieber 1993).Muscle lagis one manifestation of active insufficiency23. In the process ofrehabilitating a knee, as a regular practice, we insist that theactive range of knee extension has to be equal to the passiverange of knee extension i.e. the muscle has to have a minimumgrade of 3 where grade 3 is defined as strength of the musclewhere “The muscle can move the joint it crosses through thefull range of available motion against gravity but not against anyadditional resistance”11. But we must analyze whether activeinsufficiency can lead to a lag even in normal individuals,andthus should we rely more on functional scales and tests todetermine the level of activity the individual is at?

Janice K. Loudon et al. carried out a study, “IntraraterReliability of Functional Performance Tests for Subjects withPatellofemoral Pain Syndrome” published in the “Journal ofAthletic Training” in 2002, where they have conclude that thestep-down test has the highest reliability and the bilateral squatthe lowest.8

Also the method of testing and the time lapse in recordingthe reading need to be analyzed.

Thus this study is to determine, whether quadriceps lagexists even in normal individuals, and whether this lag increaseson sustained contraction of the muscle.

Aims and Objectives

Aim

To evaluate whether quadriceps lag exists in normal healthyadults.

Objectives

• To analyze if quadriceps lag exists in healthy adults.• To analyze how duration of sustained muscle contraction,

can affect the magnitude of quadriceps lag.• To analyze if there is any difference in the magnitude of

quadriceps lag between male and female subjects.

Methodology

Sample Size

50 subjects with 32 females and 18 males.

Age Group

20-30 years of age.

Inclusion Criteria

Healthy adults in the above mentioned age group with BMIbetween 19.9 to 29.9.

Exclusion Criteria

• Subjects with history of any trauma which would influencethe normal capacity of the knee to passively or activelyextend.

• Subjects with knee pain of any origin.• Subjects with systemic disease which might affect the

integrity of soft tissues.• Subjects on long term steroid therapy.• Any subject with more than moderate hamstring tightness.

Procedure

• All subjects have been included, keeping in mind theexclusion and inclusion criteria.

• All subjects have been evaluated for any dysfunction atthe knee and functional limitation, with the help of theevaluation form, The Cincinnati Knee Rating Scale andfunctional tests.(Appendix1,Appendix2,Appendix3)

• Functional tests have been used for the purpose ofevaluation as, the common objective measures of kneefunction, which include pain assessment, goniometry, girthmeasurement, manual muscle testing, and isokineticevaluation, are poor predictors of function. Functionaltesting is an attempt to evaluate the knee joint underconditions that mimic realistic functional demands.Performances on functional tests depends on manyvariables, including pain, swelling, crepitus, neuromuscularcoordination, muscular strength and joint stability.

• The evaluation form helps to rule out any pre-existingpathology.

• The Cincinnati knee rating scale has been chosen, as ithas been shown to have a high reliability.

• Dominance will be ascertained based on the preferred lowerlimb for kicking a ball.

• For consistency all tests were performed on the non-dominant limb.

• Each subject is made to sit in a reclined position with thetrunk supported in approximately 45degrees of flexion toeliminate hamstring tightness.

• Reflective reference markers are placed on the lateralaspect of the limb: one over the greater trochanter, one10inches distal to the greater trochanter, one on the headof the head of the fibula and one just proximal to the lateralmalleolus.

• The passive limit of knee extension has been determinedby straightening the relaxed knee, with a hand behind theheel, until the subject’s thigh is just off the plinth. In thisposition the unsupported knee is allowed to fall intoextension by the weight of the limb. The digital camera isused to record this.

• The subject was then asked to perform an active kneeextension. Instructions were given to perform as strong acontraction as possible. The digital camera is used to recordthis.

• The subject is then asked to perform an active kneeextension and hold the leg in that position for 7 seconds.The subject is also instructed not to do any secondcontraction. A video tape recording of this has beenobtained.

• Constant reinforcement was performed by the examiner,to standardize each subject’s maximum voluntarycontraction, at every instance.

• For every subject, the quadriceps lag i.e. angle of passiveextension minus the angle of active extension has beencalculated.

• The angle taken into consideration is that formed ventrally,between the axis of the leg and the thigh.

• The quadriceps lag has been measured at 1,3 and 5seconds.


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• The software used to measure the angle is photoshop5.5.The win DVD software has been used to get still shotsat the1st. , 3rd. and 5th. second.

• A comparison has been made between quadriceps lag at1second, 3 seconds and 5 seconds.

• Also a comparison between the magnitude of quadricepslag between male and female subjects, has been made.

Data Analysis

The photoshop 5.5 software has been used to measurethe passive, and active limit of knee extension at 1,3 and 5seconds.To facilitate data processing the straight knee positionwas represented as 0 degrees flexion-extension, the flexed kneerepresented by angles with a positive sign and knees beyondthe straight by angles with a negative sign. For each subject,the magnitude of quadriceps lag, that is the angular limit of activeextension minus the angular passive limit, was calculated at 1,3 and 5 seconds.

The behavior of quadriceps lag over time was tested usingrepeated measures analysis of variance (repeated measuresANOVA). This test will first identity if there are differences in thequadriceps lag over 1, 3, and 5 sec hold. The p value is set at<0.05. [f this test is significant, then post hoc analysis will bedone to identify where the difference lies. This post hoc analysisis done using paired t test with Bonferroni’s correction. Sincethere are 3 comparisons, p value is set at 0.05/3= 0.013.

The difference in lag over time between males and femaleswas analyzed using unpaired t-test with p set at <0.05.

Results

Percent of subject (n=48) who had at least the specifiedlag at 1,3 and 5 seconds after maximum active extension (Table1).


Degree Time After Maximum Active ExtensionDegree 1 second 3 seconds 5 seconds

2 83.33% 91.67% 93.75%

4 64.58% 77.08% 85.41%

6 41.66% 50% 56.25%

8 18.75 29.17% 39.58%

10 6.25% 12.5% 12.5%

12 0 4.17% 8.33%

Comparison of Extension Lag Between 1, 3 and 5 seconds

Ext. Lag at Ext. Lag at Ext. Lag at1Sec (Mean 3 sec (Mean 5 Sec (Mean

±SD) ±SD) ±SD)

5.04± 3.11 6.34 ± 3.23 7.22 ± 3.56

There was no significant difference in Extension lag betweenmales and females At 1 second

The Difference In Extension Lag between males And FemalesAt 1 Second

Males Females

Mean±S.D 5.59±2.61 4.71±3.38

It was found that there is significant difference in the quadricepslag, between 1 second and 3 seconds, 3 seconds and 5 secondsand also between 1 second and 5 seconds

The difference between males and females in extension lag at3 seconds was not found to be significant.

The Difference In Extension Lag Between Males and FemalesAt 3 Seconds

Males Females

Mean±S.D 6.66 ±2.91 6.11 ±3.32

179Shweta Basu Roy / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

The Difference In Extension Lag Between Males And FemalesAt 5 Seconds

Males Females

Mean±S.D 7.00 ±3.17 7.15 ±3.80

The difference in extension lag at 5 seconds between malesand females is non significant(p>0.5).

Discussion

It has been concluded, from the study that, quadriceps lagdoes exist even in normal healthy adults, who have no complaintspertaining to the knee, or any other health problems and areperforming all their daily activities. Also the quadriceps lagincreases over a time period of just 5seconds, significantly.

Quadriceps Lag At I second After MaximumActive Extension:

As we are aware that, the maximum number of cross-linksbetween the actin and myosin filaments and hence the maximumcontractile force in the sarcomere occurs when the full length ofthe actin strands at each end of the sarcomere are in contactwith the myosin molecule. Increased shortening causes the actinstrands from each end of the sarcomere to interfere with eachother. This reduces the number of available sites for cross-bridgeformation, and the force of contraction decreases, and thus thenumber of cross-links that can be made again diminishes.Consequently the force of contraction decreases leading to whatis termed as active insufficiency of a muscle7.19.

Also quadriceps femoris is a pennate muscle with a largephysiological cross-sectional area, but short fibers, whichfacilitates large force producing capacity but limits its ability toprovide a large excursion19 .

In checking the strength of the quadriceps femoris musclewe have to also consider that ,the force of gravity acts throughthe center of gravity, which, in an open chain activity, is foundon the side of the moving segment. In a seated knee extensionexercise, the center of gravity will be found on the tibial side ofthe knee. In the seated position with the knee at 90 degrees ,the center of gravity is aligned with the axis of the knee in sucha way that it creates no rotation of the knee. In other words thequadriceps does not need to contract against the force of gravityto maintain the knee in this position. During knee extension, theleg moves toward a position in which it is parallel to the ground.As this occurs, the resistance by gravity will increase and reachits maximum when the leg is parallel to the ground. Therefore inorder to extend the knee in this position, the quadriceps mustproduce an increasing amount of force with the greatest forcerequired when the resistance of gravity is greatest (knee in fullextension)7,19.Thus a muscle that might function perfectly and

give rise to no functional deficits, may still not be able toeffortlessly completely that last 5 degrees of knee extension.

In addition to the above, the role of the patella, as ananatomical pulley to increase the moment arm of the quadriceps,decreases in the last 15 degrees of knee extension, and thusthe muscle requires to increase the force production by 60% tocomplete this range4.

Increase in Quadriceps Lag Over Time:

As stated in literature when a bone on which a muscle isinserted, moves from a position of suspension in the verticalplane toward the horizontal plane, as in the quadriceps, deltoidand hip rotators tested in the sitting position and the triceps andshoulder rotators tested in the prone position, the weight of thepart of the increases, as the part moves toward completion ofarc, and the muscle strength required to hold the contractionagainst gravity usually is sufficient to perform the movement .Thus in case of the quadriceps where the tibia moves from thevertical to the horizontal position it is more difficult to hold theposition than to perform the movement11.

Thus the above study was conducted to make the clinicianaware of the following vital points which will aid in judging thestrength of the quadriceps better:

A delay of several seconds is not unusual as cliniciansattempt to estimate knee joint angles visually, or to measurethese angles with some form of goniometer.

Several seconds can easily be used to align the instrumentcorrectly and another several seconds to read the scale correctly.The present study has revealed that delays of 3 seconds ormore produce significantly larger values of quadriceps lag. Inpatients with knee pathology, where the rate of quadriceps fatiguemay be greater than in normal individuals, this problem is likelyto be more profound.

Accordingly, it is recommended that clinicians note the timetaken to derive measures of maximum active knee extensionduring quadriceps lag test, and attempt to standardize this timeduring all subsequent measures for the same subject. As statedin the study done by Stilman et al., it could also be helpful inminimizing time delays during measurement, to employ suchstrategies as:√ Pre-marking surface landmarks on the skin to facilitate

positioning of a goniometer.√ Attaching the instrument to the limb before commencing

the tests√ Asking a second person to assist

Conclusion

Thus from the above study it has been concluded that:√ Quadriceps lag does exist, in healthy adults with intact knee

function√ The quadriceps lag increases over time i.e. within a time

span as less as 5 seconds.√ No correlation exists between hyperextension and

quadriceps lag.√ The quadriceps lag, does not differ on the basis of gender.


√ The study can be conducted on a larger population, as thenumber of subjects included in the current study may notbe enough to reach conclusive statements.

√ A comparative study of quadriceps lag in the different agegroups can be conducted, to give us a better idea abouthow age could affect the lag.

√ A study on people of different fitness levels need to becarried out, to prepare us at to what we should expect,when evaluating subjects with different activity levels.

180

√ A more advanced software if available can be used toimprove the accuracy of the study.

References

1. ‘ E. J. Miller, J. D. MacDougall, M. A. Tarnopolsky and D. G.Sale , Gender differences in strength and muscle fibercharacteristics, European Journal of Applied Physiology.Volume 66. Number 3 / March, 1993

2. Cailliet Rene,MD. Pain Series,Soft Tissue Pain AndDisability(2nd. Edition), New Dehi, Jaypee Brothers MedicalPublishers (P) Ltd. Pg. 275

3. C.J. de Ruiter,R.D. ,Kooistra,M.I. Paalman and A. deHaan;Initial Phase of maximal voluntary and electricallystimulated knee extension torque development at differentknee angles;Journal of Applied Physiology97:1693-1701,2004.

4. David J. Magee, Phd. , BPT. , Orthopedic PhysicalAssessment (4th. Edition), New Delhi, Harcourt PrivateLimited. Pg. 675

5. Does Legedness Exist? An Evaluation Study To DetermineLower Extremity Dominance, Vol. 1- Issue 1- March 2005

6. ES Grood, WJ Suntay,FR Noyes and DLButler:Biomechanics of Knee Extension Exercise:Effect ofCutting The Anterior Cruciate Ligament: The Journal ofBone and Joint Surgery, Vol.66, Issue 5, 725-734

7. Guyton & Hall; Textbook of Medical Physiology; 10th.Edition; Saunders; Pg.67-72

8. James R. Andrews, M.D. , Gary L. Harrelson, Ed.D. , A.T.C.Kevin E. Wilk; Physical Rehabilitation of The InjuredAthlete,2nd. Edition, W.B. Saunders Company, Pg.342,344,350,395

9. Janice K. Loudon, Doug Wiesner, Heather L. Goist Foley,Can Asjes, and Karen L.Loudon: Intrarater Reliability ofFunctional Performance Tests For Subjects WithPatellofemoral Pain Syndrome; Journal of Athletic Training.2002 July-September; 37(3):256-261

10. Kapandji I. A., The Physiology Of The Joints, (5th. Edition),Edinburgh, London, Melbourne and New York, ChurchillLivingstone Pg. 138

11. Keitaro Kubo & Naoya Tsunoda JE Hiroaki Kanehisa,Tetsuo Fukunaga; Activation of agonist and antagonistmuscles at different joint angles during maximal isometricefforts, European Journal of Applied Physiology

12. Kendall, Muscle Function and Testing13. Kumar A. , Bilateral Sequential Rupture of Quadriceps

Tendon, Department of Trauma and Orthopedics, RussellsHall Hospital, Dudley, Westmindlands, UK

14. Kyle R., Flik, MD; Charlesa. Bush Joseph, MD; Bernard R.

Bach, JR, MD(2005), Complete Rupture Of Large Tendons,Risk Factors, Signs and Definitive Treatment, The Physicianand Sports Medicine, Vol. 33 No. 8

15. Levangie Pamela K. , Norkin Cynthia C. , Joint Structureand Function, A Comprehensive Analysis (3rd. Edition),New Delhi, Jaypee Brothers, Medieval Publishers (P) Ltd.Pg. 343-346, 349-351

16. MARX Robert G. JONES Edward C. ; ALLEN Answorth A.;ALTCHEK David W. ; O’BRIEN Stephen J. ; RODEO ScottA. (1) ; WILLIAMS Riley J.(1) ; WARREN Russell F.(1) ;WICKIEWICZ Thomas L.{1) ; Reliability, validity, andresponsiveness of four knee outcome scales for athleticpatients, Journal of bone and joint surgery. Americanvolume,2001, vol. 83, pp. 1459-1469

17. “ Mosher Timothy J., MD. , Knee extensor mechanisminjuries, e-medicine, googlesearch

18. Nicolas Babault, Michel Pousson, Anne Michaut, andJacques Van Hoecke:Effect of Quadriceps Femoris MuscleLength On Neural Activation During Isometric andConcentric Contractions: Journal of Applied Physiology,94:983-990, 2003

19. Oatis Carol A. , PT, Phd. , Kinesiology, The Mechanics andPathomechanics of Human Movement, Philadelphia,Pennsylvania, Lippincott Williams & Wilkins, Pg.48-49;51-60;711-715;739-757

20. P. AAGAARD, E. B. SIMONSEN, J. L. ANDERSEN, S. P.MAGNUSSON,

21. HALKJAER-KRISTENSEN, AND P. DYHRE-POULSEN,Neural inhibition during maximal eccentric and concentric,quadriceps contraction: effects of resistance training

22. JAppl Physiology, 89: 2249-2257, 2000.23. Richard L. Lieber, Ph.D., Skeletal Muscle is a Biological

Example of a Linear Electro-Active Actuator, Proceedingsof SPIE’s 6th Annual International Symposium on SmartStructures and Materials, 1-5 March, 1999, San Diego,

24. CA. Paper No. 3669-03.25. R. J. Maughan, M. Harmon, J. B. Leiper, D. Sale and A.

Delman , Endurance capacity of untrained males andfemales in isometric and dynamic muscular contractions,European Journal of Applied Physiology, Volume 55,Number 4 / August. 1986, 395-400

26. R.S. Lindle, E.J. Metter, N.A. Lynch, J.L. Fleg, J.L. Fozard,J. Tobin, T.A. Roy, and B.F. Hurley: Age and GenderComparisons of Muscle Strength in 654 Women and MenAged 20-93year, Journal of Applied Physiology, 83(5):1581-1587,1997

27. 351 Stillman BC(204) Physiological Quadriceps Lag: ItsNature and Clinical Significance, Australlian Journal ofPhysiotherapy, 50:237-241


181

Effect of Play Therapy on Functional Reach in Stroke CasesSurinder Pal SinghOccupational Therapist, National Institute for the Orthopedically Handicapped, B.T.Road, Bon-Hoogly, Kolkata (WB)

Surinder Pal Singh / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Objective

To study the effect of play therapy on functional reach instroke patient

Design

Pretest-posttest experimental group design

Setting

Occupational therapy department, SVNIRTAR, Cuttack,Orrisa

Subjects

Thirty male patients with stroke were included in the study.The mean age of experimental group was 46.13 and controlgroup was 43.60.

Intervention

Experimental group received play therapy along withconventional therapy and Control group received conventionaltherapy only for 5 days a week for 4 weeks

Outcome Measure

Out come was measured using functional reach test.

Results

Within group comparison shows statistically significantimprovement in both the groups (p< 0.05). On between groupcomparison experimental group shows statistically greaterimprovement in functional reach score as compare to controlgroup (p<0.05).

Conclusion

Addition of play therapy along with conventional therapyshown greater improvement as compared to conventionaltherapy alone. So Play therapy can be efficiently added in clinicalpractice for treating stroke patients.

Key Words

Stroke, Play therapy, Functional reach.

Introduction

Stroke is defined by the National Institute of NeurologicDisorders and stroke (NINDS), USA as a sudden loss of brainfunction resulting from an interference with blood supply to thebrain. (Sethi PK, 2002).

A review of information available on stroke was conducted

by Anand K et al to estimate the morbidity due to stroke in India.The prevalence of stroke in India was estimated as 203 per100,000 population above 20 years, amounting to a total of about1 million cases. The male to female ratio was 1.7. Around 12%of all stroke occurred in population below 40 years. The estimatedstroke mortality was 102,000, which represented 1.2% of totaldeaths in the country. (Sethi PK, 2002).

The reaching movement, a complicated multi jointmovement directed to a defined point in space (GeorgopoulosA P ,1986), is the major action of the arm to bring the hand intointeraction with the environment (Shepherd R B , 1995).

Problems with reach, grasp and manipulation affect manyof the activities performed in daily life such as dressing, eatingand grooming. As such they are a major focus of interventionfor clinicians involved in the rehabilitation of patients withneurological pathology (Duff S et al , 2000). Reaching is, thus,an important movement to study in persons who have sufferedstroke (Wu C Y et al ,2000).

Games have been shown to be effective therapeutic toolsfor children and adults. Games can be used to increase strengthand stamina, promote functional movement patterns, improvedexterity and grasp, and foster cognitive and psychosocial skills(Avedon , 1971). Extension form of Games are “playful therapy’(Hoppes S et al, 2001).

The use of meaningful activity to enhance the value oftherapy and improve performance lies at the heart ofOccupational therapy (Bundy AC, 1993).

Can play be a meaningful activity for adults? Can play, infact, be used therapeutically with adults to increase functionalreaching ability and prevent disability?

So purpose of this study was to see the effect of play therapyon functional reach in stroke cases.

Methodology

Research Design

A prospective, structure, different subject, experimentaldesign. The subjects were measured for ‘Functional Reach’ preand post treatment in both groups.

Independent variable- Play therapyDependent variable- Functional reach

Subjects and Setting

A total of 30 hemiplegic patients were selected frominpatient and outpatient coming to Occupational therapydepartment. The patients were explained the purpose of thestudy and were requested to participate in the study and a writtenconsent was obtained from each patient.

Patients were randomly assigned into two groups-A. Experimental group (15 subjects)B. Control group (15 subjects)Experimental group received designed protocol based on

‘play therapy’ (for 30 minutes in afternoon session) in additionto ‘conventional occupational therapy’ (for 30 minutes in morningsession) per day and control group received ‘conventionaloccupational therapy’ alone (for 30 minutes in morning session)per day for 4 weeks (5 days a week ).

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Inclusion Criteria

1. Adult stroke patients of either sex.2. Right or left sided hemiplegia.3. Subjects undergoing rehabilitation after first episode of

stroke.4. Duration of stroke not less than three months.5. A score of more than 24 in Mini Mental State Examination.6. Able to maintain standing for at least 10 minutes.7. Spasticity 1 to 1+ on Modified Ashworth Scale.

Exclusion Criteria

1. Unable to maintain standing for atleast 10 minutes.2. Unable to sit unsupported for atleast 10 minutes.3. Concurrent cerebellar and brainstem lesion.4. Visual spatial hemineglect or apraxia.5. Sensory impairment in involved limb.6. Any other medical condition which affect the participation

in the therapy.

Instrumentation

Screening toolsa Modified Ashworth Scale (Bohannon RW and Smith MD,

1987).b Perception of Joint Position Sense Test (Leo K and

Soderberg,1981).c The Single Letter Cancellation Test (Diller et al, 1974).

Outcome Measures

Functional reach test (Duncan et al, 1990).

Procedure

Evaluation

Before doing evaluation demographic data like name, age,sex, duration of stroke from onset, side of body involvement,was recorded. Patients were evaluated for functional reach, bothat the beginning and end of intervention.

Test

Mini Mental State Examination was administered to knowthe patient’s awareness regarding orientation, registration,attention, etc. (Folstein et al, 1975 ).


Protocol for group A in each session:

Sl. No. Name of game Duration of game(in minutes)

1 Ball into basket 5

2 Balls into well 5

3 Throw and catch 5

4 Hit the target 5

After completing two games there was a rest period of 10minutes. Thus a total of 30 minutes play therapy session wasthere in afternoon with 30 minutes of conventional therapy inmorning.

Protocol for group B in each session:

The conventional therapy included therapy for both upperand lower limbs based on integrated approach.

Procedure for Group A:

1. Ball into basket.While sitting unsupported on a stool of appropriate height,

seat depth, and width; patient threw a ball into a basket by bothhands. The basket was placed at a height of 5 feet from groundand 8 feet away from patient. The number of times patientsucceeded in putting the ball into basket in a period of 5 minuteswas taken as score.

2. Balls into well.While sitting unsupported on a stool, patient picked up small

balls one at a time with his impaired limb, reaching forward,backward, side wards. Balls were scattered on the floor allaround the patient. After picking up the ball, the patient threw itinto a large box (well) 8 feet in length, 4 feet in height, 3 feet inwidth, placed 8 feet away from patient. In a period of 5 minutes,number of balls patient successfully threw into well was takenas score

3. Throw and catchWhile standing, the patient threw a ball with both hands

towards wall which was 8 feet away. The ball was thrown fromat or above shoulder level and the patient caught the ball withboth hands as it bounced back. In a period of 5 minutes thenumber of times patient succeeded in catching the ball afterbouncing from wall was taken as score.

4. Hit the targetWhile standing, the patient hit a target 15 inch height at 5

feet above the ground and 8 feet away from patient by his bothhands. In a period of 5 minutes the number of times the patientsucceeded in hitting the target was taken as score.

Distance between patient and target, distance of target fromground, size of target was adjusted in order to provide just rightchallenge to patient.

Procedure for Group B:

All activities such as working on transfers, balance, activitiesof daily living training also along with neurodevelopmental andneurophysiological techniques like weight bearing, bilateralactivities etc were carried out. Duration of each session was 30minutes.

Data Analysis

Mean and Standard deviation was used to determine thesubject’s characteristics of both control and experimental groupsin terms of age, duration of CVA.

For statistical analysis, the parametric paired t test was usedfor determining changes after treatment within each group. Theunpaired t test was used to compare the therapeutic resultsbetween the two groups.

Functional reach score taken before treatment and aftertreatment along with demographic data were analyzed usingStatistical Package for the Social sciences (SPSS) version 16.An alpha level of p < 0.05 was used for all tests of significance.

Results

The individual characteristics of experimental and controlgroups are given in Table-1 Experimental group consisted of 15subjects (all males). Mean age ± standard deviation of the groupwas found to be 46.133 ± 9.789 years. Also the mean duration

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± standard deviation since onset of stroke for the group wasfound to be 9.533 ± 3.292 months.

The control group consisted of 15 subjects (all males). Meanage ± standard deviation of the group was found to be 43.600 ±10.01 years. And the mean duration since onset of stroke forthe group was found to be 8.8667 ± 3.24844 months.

Changes within each group is shown in Table – 2 and wasfound by using paired‘t’ test. Both the groups exhibited within

Table 1: Patients demographics

MEAN (SD)

Group A AGE (in years) 46.13±9.78

N=15 DUR.(in months) 9.53±3.29

Group B AGE(in years) 43.60±10.01

N=15 DUR.(in months) 8.86±3.24

group statistically significant improvement between pre and postscores in outcome measure Functional Reach Test (p<0.05).

Between group changes are shown in Table–3. Comparisonbetween the groups for changes in the score through unpaired‘t’ test showed that there is statistically significant differencebetween experimental and control groups (p<0.05).

Table 2: Within group comparison of functional reach test

Pretest value Posttest value paired t-testMean (SD) Mean(SD) t p

Group A 4.80 (0.67) 7.43 (0.73) -18.547 .000

Group B 4.60 (0.50) 5.86 (0.69) -7.536 .000

Table 3: Between group comparison of functional reach test

Group A Group B unpaired t-testMean(SD) Mean (SD) t p

Pretest 4.80 (0.67) 4.60 (0.50) .917 .367value

Posttest 7.43 (0.73) 5.86 (0.69) 5.620 .000value

Discussion

The purpose of the study was to determine if similartherapeutic protocols (i.e. conventional occupational therapy)were administered, stroke patients who underwent play therapyin addition would exhibit greater improvement of functional reachthan those who received the conventional occupational therapyalone.

This study was stimulated by apparent progresswitnessed in different patients when play was used (SakemillerL.M. & Nelson D.L., 1998; Beauregard R., 1998; Hoppes S.,1997; Sietsema J.M. et al, 1993). The use of meaningful activitiesin occupational therapy intervention assists neurologicallyinvolved patients in improving motor control (Sabari J.S., 1991).

When spasticity develops, early occupational therapyintervention is essential to maintain function and promote motorrelearning. A well-known characteristic of the early phase ofmotor skill learning is that concentration is necessary to processthe information needed to perform (Fitts & Posner, 1967;Marteniuk, 1979). Therefore, a major challenge is to structureoccupations that require the use of the client’s involved spasticarm while invoking his or her optimum motivation.

Mosey (1986) emphasized this need for structuringoccupationally embedded exercise because ‘performancecomponents are not acquired through random activity ormindless exercise; rather they are acquired through active, goal-directed interaction with the environment.

As the patients enjoyed so much the play during the therapy

session, that whenever they succeeded they exclaimed yeah!or made a sound out of excitement. This could also havefacilitated the achievement of more improvements in reach inexperimental group, as is evidenced by Maitra K K et al (2006)that self-vocalization induces facilitation of reach.

Contextual effects of play activities in seated position, objectaffordances, task goal, and task-related training could contributeto benefits.(Wu C Y et al,2000;1998; 2001; Dean C M et al,1997; Thielman G T et al,2004).

During standing also play activities contributed to reachingenhancement as this was also observed in study by Lin K C etal (2007).

As the patients were externally focused during play activitiesthis resulted in greater gain in reach. Same were the findings ofFasoli S E et al (2002).

This study supported the hypothesis that the occupationallyembedded intervention as an adjunct to conventionaloccupational therapy promoted more range of functional reachthan did conventional occupational therapy alone. Hitting thetarget and throwing ball into well provided motivating feedbackto enhance performance, and the game promoted moreenthusiasm and increased attention span.

Subjects required less cuing during the occupationallyembedded condition and many subjects continued playing afterthey had completed 10 repetitions.


• Small sample size.• Follow up study to know retention of effects of play therapy

was not done.• Limited varieties of play were used.• Only male subjects.


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Recommendations for further Study

Further study is required to determine the carryover ofeffects on functional improvements.• Group therapy session may be added to make therapy

sessions more interactive, enjoyable and competitive.• Similar studies are required for finding out improvement in

hand functions.• Similar studies are required for finding out improvement in

hand functions.

Conclusion

After analyzing the result we can conclude that addition ofplay therapy along with conventional therapy shown greaterimprovement as compared to conventional therapy alone. SoPlay therapy can be efficiently added in clinical practice fortreating stroke patients.

References

Avedon EM (1971). Cited by Hoppes S, Hally C, Swell L (2000).An interest inventory of games for older adults. Physical andOccupational therapy in geriatrics. 18, (2), 71-83Beauregard R et al (1998). Quality of reach during a game andduring a rote movement in children with cerebral palsy. Physicaland occupational therapy in pediatrics. 18, 67-84Bundy AC (1993). Cited by Hoppes S et al (2001). Meanings ofplay for older adults. Physical & Occupational Therapy inGeriatrics. 18. 57-67.Bohannon RW, Smith MD (1987). Inter rater reliability of amodified ashworth scale of muscle spasticity. Physical therapy.67. pg 206-207Dean CM et al (1997). Task-related training improvesperformance of seated reaching tasks after stroke. Stroke. 28.722-728.Diller, et al (1974). In http://www.medicine.mcgill.ca/strokengineassess/module_slct_indepth-en.htmlDuff S, Cook AS, Woollacott M (2000). Clinical management ofthe patient with reach, grasp, and manipulation disorders. InCook AS, Woollacott MH. 2nd edition. Motor control: theory andpractical application. Lippincott Williams and Wilkins. pg 517.Duncan P et al (1990). Cited by O’Sullivan SB and Schmitz TJ(2007). Examination of motor function. Gutman SA, Marx R,Scott AH. 5thedition. Physical rehabilitation. New Delhi. Jaypeebrothers medical publishers (p) ltd.Fasoli SE et al (2002). Effect of instructions on functional reachin persons with and without cerebrovascular accident. Americanjournal of occupational therapy. 56. 380-390.Folstein M, Folstein SE, McHugh PR (1975). In http://www.patient.co.uk/showdoc/40000152/Fitts & Posner (1967). Cited by Sietsema JM et al (1993). Theuse of a game to promote arm reach in persons with traumatic

brain injury. The American journal of occupational therapy. Vol47. 19-24.Georgopoulos A P et al (1986). Cited by van Vliet P. (1999).Reaching, pointing and using two hands together. Durward BR,Baer GD, Rowe PJ. Functional human movement: measurementand analysis. Oxford. Butterworth-Heinemann.Hoppes S et al ( 2001). Meanings of play for older adults.Physical & Occupational Therapy in Geriatrics. 18. 57-67.Lin K C et al (2007). Effects of object use on reaching andpostural balance. American journal of physical medicine andrehabilitation. 86. 791-799.Leo K, Soderberg G (1981). Relationship between perceptionof joint position sense and limb synergies in patients withhemiplegia.Physical therapy. 61. Pg 1433-1437Maitra KK et al (2006). Self-speech-induced facilitation ofsimplereaching movements in persons with stroke. Americanjournal of occupational therapy. 60. 146-154.Mosey (1986). Cited by Sietsema JM et al (1993). The use of agame to promote arm reach in persons with traumatic brain injury.The American journal of occupational therapy. 47. 19-24.Marteniuk (1979). Cited by Sietsema JM et al (1993). The useof a game to promote arm reach in persons with traumatic braininjury. The American journal of occupational therapy. Vol 47.19-24.Sethi PK (2002). Stroke-incidence in India and management ofischaemic stroke. Neurosciences today. 3. 139-143.Sakemiller LM and Nelson DL (1998). Eliciting functionalextension in prone through the use of a game. The Americanjournal of occupational therapy. 52. 150-157.Shepherd RB (1995). Cited by Wu CY, D Sc, Trombly CA, LinKC, Degnen LT (2000). A kinematic study of contextual effectson reaching performance in persons with and without stroke:influences of object availability. Archives of physical medicineand rehabilitation.41. pg 96.Sietsema JM et al (1993). The use of a game to promote armreach in persons with traumatic brain injury. The American journalof occupational therapy. 47. 19-24.Sabari JS (1991). Cited by Sabari JS (1991). Motor learningconcepts applied to activity-based intervention with adults withhemiplegia. The American journal of occupational therapy.Vol.45. 523-530.Theilman GT et al (2004). Rehabilitation of reaching after stroke:task-related training versus progressive resistive exercise.Archives of physical medicine and rehabilitation. 85. 1613-1618.Wu CY et al (2001). Effects of task goal and personal preferenceon seated reaching kinematics after stroke. Stroke. 32. 70-76.Wu CY et al (2000). A kinematic study of contextual effects onreaching performance in persons with and without stroke:influences of object availability. Archives of physical medicineand rehabilitation.81. 95-101.Wu CY et al (1998). Effects of object affordances on reachingperformance in persons with and without cerebrovascularaccident. The American journal of occupational therapy. 52. 447-456.


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Effect of Deep Transverse Friction Massage and CapsularStretching in Idiopathic Adhesive CapsulitisVaishali Chauhan, Shobhit Saxena, Shalini GroverDepartment of Physiotherapy, Faridabad Institute of Technology, Faridabad, Haryana

Vaishali Chauhan / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

Abstract

Study Design

The study was a randomized controlled trial. This studywas reviewed and approved by the research review committeeat Faridabad Institute of Technology. (Faridabad).

Objective

To determine the effect of deep friction massage andcapsular stretching in idiopathic adhesive capsulitis.

Background

Studies have shown the effect on deep transverse frictionmassage and manipulation together. This study is being doneto see the effect of deep friction massage and capsular stretchingtogether; on supraspinatus and subscapsularis muscle as thesetwo muscles are will be effective in improving the range of motionand pain with functional disability in adhesive capsulitis.

Methods and Measures

Twenty six patients with primary diagnosis of adhesivecapsulitis (both men and women; mean age 40-60 years) andexhibiting a specific abduction, medial rotation and externalrotation range of motion deficit will be randomised into twotreatment groups.

The first group (Experimental group) will be receiving theCyriax approach of deep friction massage on supraspinatus andthe subscapsularis with inferior capsular stretching, hot packs,active assisted exercises and home exercise programs for aperiod of two weeks. The second group (control group) will bereceiving the same except Cyriax technique. The initialevaluation will be including the recording of detailed medicaland physiotherapy history and assessment of range of motionusing goniometer, pain using visual analogue scale with disabilityusing shoulder pain and disability index (SPDAI).

Results

Improvement in shoulder abduction, internal and externalrotation values along with functional disability and the decreasein pain were significantly better in the Experimental group afterthe first and second week of treatment.

Conclusion

The Cyriax method of rehabilitation provides a faster andbetter response than the conventional physical therapy methodsin treatment of adhesive capsulitis.

Introduction

Shoulder pain is among the most common reasons for visitsto a general practitioner. The point prevalence of shoulder painis estimated to be 4-20% at any given time1, 2. Prospective studies

in Europe have shown that approximately 11 out of 1000 patientshave shoulder pain5. Most people under the age of 40 with ashoulder problem have rotator cuff lesions3, 4. Adhesive capsulitis(frozen shoulder) is an insidious painful condition with gradualrestriction of all planes of movement in shoulder. Adhesivecapsulitis affects 2-3% of the general population and is the maincause of shoulder pain and dysfunction in individuals aged 40-70 years according to the data collected in 199710.

Idiopathic adhesive capsulitis is characterized by fibrosisof capsule resulting with progressive painful loss of active &passive shoulder motion. It affects 20% of people with diabetes.Other factors associated with adhesive capsulitis include femalegender, trauma, immobilization, thyroid disease, stroke,myocardial infarction, autoimmune diseases, cervical spinedisorders & reflex sympathetic dystrophy6, 11.

Neviaser(1945) coined the term adhesive capsulitis 8,9.Cyriax therapy is one of the manual therapies. It includesmanipulation, mobilization, traction techniques and deep frictionmassage for extremities. Deep transverse friction massagemainly indicated for treating muscles, tendon, joints capsule andligaments13.

Cyriax (1983) proposed that tightness in a joint capsuleresults in a proportional pattern

of motion restriction. For the shoulder, he predicted thatexternal rotation would be more limited than abduction, whichwould be more limited than internal rotation (capsular pattern)12.

Rundquista et al findings did not support Cyriax’s proposedglenohumeral capsular pattern and concluded that internalrotation was the most limited motion in 23 out of 25 (92%)involved shoulders19. Stadnick, (2005) founded that MRI showed,that the rotator interval and the axillary recess, were commonlyaffected by adhesive capsulitis.

The rotator interval lies between the supraspinatus muscleand tendon posterosuperiorly and the subscapularis muscle andtendon anteroinferiorly15.

Deep transverse friction causes traumatic hyperaemia,which helps to evacuate pain triggering metabolites1.It, helps inmovement of the affected structure, which prevents or destroysadhesions and optimizes the quality of the scar tissue15, 16.According to Cyriax, deep transverse friction massage restoresmobility to the muscle in same way that mobilization frees ajoint17, 18

Methods

Through convenience sampling, 30 subjects (both maleand females) were recruited from the patients referred to OPDof physiotherapy department of Bhagwan Mahavir Hospital,Delhi. The subjects recruited through screening, were thenrandomly assigned to one of the two treatment groups -Experimental group and Control group via simple randomizatiommethod.

Inclusion Criteria

(1) Primary adhesive capsulitis or idiopathic. (2) Age shouldbe of 40 -60 years: both males and females recruited. (3)Shoulder pain and loss of range of motion more than 2 monthsbut less than 1 year (minimum). (4) Normal findings on anterior-

186 Vaishali Chauhan / Indian Journal of Physiotherapy and Occupational Therapy. Oct.-Dec., 2011, Vol.5, No.4

posterior & axillary lateral radiographs of glenohumeral joint.(5) Absence of any rheumatoid tendinous lesions, local sepsisand skin diseases. (6) Range of motion loss of 50% or greaterthan the non involved shoulder (in abduction). (7) SufficientEnglish to complete the questionnaires.

EXclusion Criteria

(1) Presence of any medical condition like cardiac diseaseand diabetes mellitus. (2) Patients who had adhesive capsulitissecondary to shoulder dislocation, fractures. (3) Disorder likeshoulder diseases, reflex sympathetic dystrophy, rotator cuffinjuries, rheumatoid arthritis and ankylosingspondylitis.(4).Patients with bilateral involvement of shoulder (5)Presence of cervical radiculopathy (6) Patients who have priorto shoulder surgery.

Intervention

Experimental group received deep transverse frictionmassage of the two tendon supraspinatus and subscapularisas laid by Cyriax , followed by inferior capsular stretching ,passive range of motion exercises, hot packs and homeexercises program. Control group received hot packs, and homeprogram. All patients were treated for 6 sessions (3 days aweek for 2 weeks). Deep friction is given transverse to the fiberdirection usually 15 per session with hourly session in hospital3 times a week.

(b)

(a)

Supraspinatus tenoperiosteal junction transverse frictionmassage (b) Supraspinatus musculotendinous junctiontransverse friction massage (c) Capsular stretching (d)Subscapsularis tenoperiosteal junction friction massage


Total thirty subjects were recruited and were randomlyassigned to 2 groups. The experimental group consisted of 6males and 7 females whereas control group consisted of 5 malesand 8 females as in Experimental group 1 and in control group3 subjects were unable to continue the treatment. All the subjectswere similar at baseline with regards to age and duration ofsymptoms.

Normality of variables was checked by histograms.Parametric tests were applied for the normally distributed data.The characteristics of the data were presented through tablesand graphs. Pre-treatment and post-treatment pain, disabilityand range of motion values were compared within each groupwith repeated mesures ANOVA and the progression betweentretment sessions were explained through paired –t test withBonferroni correction. Independent (Unpaired) t-test wasperformed to analyze the intergroup difference in pain , disabilityand range of motion after performance of deep friction massageand capsular stretching at different sessions. The results wereconsidered statistically significant if p=0.05.

Results

Analysis of VAS scores between experimental and controlgroup at baseline ,at the end of 1st session (day1) , 2nd session(day3) , 3rd session (day5), 4th session (day7) , 5th session(day9) and 6th session (day11). There was no significantdifference between two groups initially, however significantdifference found on day7 (p=0.047), day9 (p= 0.035) & day11(p=0.13).

The analysis of scores SPDAI between both the groupssuggested that there was non- significant differences at thebaseline (p=0.140) and at the end of 3rdsession (p =.071) butafter 6th session experimental group showed significant

(c)

(d)

187

Graph 2.1: Comparison of pain in both the groups

Graph 2.2: Comparison of SPADI in both the groups

improvement than control group with a value of p = 0.020 <0.05. Experimental group showed to be significant than controlgroup having p=0.041<0.05 at the end of 6th session in abduction.

Experimental group showed improvement in lateral rotationand medial rotation after each session but the difference infrequencies did not reach statistical significance.

Graph 2.3: Comparison of abduction in both the groups

Graph 2.4: Comparison of Lateral rotation in both the groups

Graph 2.5: Comparison of medial rotataion in both groups

Percentage of improvement for both the groups

Outcome Experimental Controlmeasures group(%) group(%)

VAS 43.90 23.82

SPADI 37.60 26.10

Abduction 33.53 17.60

Lateral rotation 35.80 28.20

Medial rotation 35.60 21.00

Graph of Percentage of improvement for both the groups


Discussion

The purpose of this study was to determine the effect ofdeep transverse friction massage and capsular stretching onpain, range of motion and functional disability in idiopathicadhesive capsulitis. In both the groups experimental and control

group, pain, disability and range of motion were taken as thedependent variables to assess the improvement between thegroup and within the group. The findings of the present studysuggest that the addition of deep friction massage and capsularstretching along with conventional physiotherapy reducespatient’s pain more effectively than control group alone over a 2week period. Statistically significant improvements were alsofound in the both dependent variables in both the groups hadhomogenous distribution of patients.

Abduction showed significant difference betweenexperimental and control group. However, the inter groupdifference of lateral and medial rotation reached particular rangeof motion after the 3rd and 6th session, but the difference in thefrequencies did not reach statistical significance.

With regards to pain, Experimental group improved betterthan control group in VAS scores at 4th 5th and the 6th sessiongiving a statistical difference between the two groups. Both thegroups showed that pain improve with deep friction massagetreatment. These findings are consistent with the results KaadaB and Field, who found that mechanism through which reductionin pain may be achieved is through diffuse noxious inhibitorycontrols, a pain suppression mechanism that releasesendogenous opiates. According to Cyriax, friction also leads toincreased destruction of pain provoking metabolites, such asLewis’s substances. This metabolite, if present in too high aconcentration, provokes ischaemia and pain1, 12.

The introduction of deep friction massage and capsularstretching in the experimental group supports between group

188

comparison results. The between group VAS score comparisonwas found insignificant at the end of 4th session. Theimprovement in pain intensity was maintained in both the groupsat 6th session but statistically results favored the experimentalgroup.

It was also noted that both the groups showed significantimprovement in abduction and for lateral and medial rotationranges of motion ,improvement between the both groups wereshown but the difference in the frequencies did not reachstatistical significance, the reason for this may be that if thestudy was carried for more than two weeks than it might possibleto achieve significant difference for both the other range ofmotions, moreover this study include deep transverse frictionmassage on supraspinatus muscle, at two junctions namelytenoperiosteal & musculotendinous junction along with capsularstretching of inferior capsule , thus thereby resulting in significantimprovement in abduction at shoulder joint within the period ofthe study13,16. Deep friction massage are intended to produceincreases in range of motion on the basis of biomechanical effectwhich manifests itself when forces are directed towardsresistance but within the limits of a subject’s tolerance. Themechanical changes may include breaking up of adhesions,realigning collagen when specific movements stress the specificparts of the capsular tissue. There was no statistically significantdifference at the baseline between the two groups. Theimprovement was found in both the groups, a slight more towardsthe experimental group at the end of 3rd and 6th session. Thepossible reason for non-significant difference between twogroups at the end of 1st and 2nd session could be a small samplesize limiting statistical power and administration of treatment inboth the groups. The results suggest that the experimental grouphas more maintained improvement than the control group. Thelimitation of the study would be the sample size was small anddata was collected from limited places that limit thegeneralizability of the results. Also the study period is short andno follow up was taken. Neither the subjects nor the therapistwere blinded to group assignment.Since the results of this studycannot be generalized to other subjects with secondary adhesivecapsulitis as a result of diabetes, cardiac problems, stroke ortrauma. So the effectiveness of deep transverse friction massageand capsular stretching techniques in these groups need to befurther evaluated.

Conclusion

The analysis of the data collected showed that deep frictionmassage and capsular stretching to experimental groupproduced significant improvement in pain and disability scoresat the end of 2nd week. However, deep friction massage andcapsular stretching produce improvement between the bothgroups for rotation ranges of motion, but the difference in thefrequencies did not reach statistical significance, exceptabduction which showed significant improvement at the end of2nd week. These results partly accept and partly reject theexperimental hypothesis suggesting that using deep frictionmassage and capsular stretching in experimental group willproduce statistically significant difference in pain, disability andranges of motion.

Refrences

1. Fusun Guler-Uysal, Erkan Kozanoglu : Comparison of theearly response to two methods of rehabilitation in adhesivecapsulitis.Swiss med wkly 2004 ; 134:353 – 358

2. Kingkaew pajarey, Navapornchadchavalpanichaya,Somluck

3. Painmanakit,Chanjira kaidwan ,Patcharin puttaruksa ,Yananee wongsaranuchit,Cyriax. Effectiveness of physicaltherapy for patients with adhesive capsulitis: a randomizedcontrolled trial. J Med Assoc Thai 2004; 87(5): 473-80

4. F. E. Bruckner and C. J. S.Nye .A Prospective Study ofAdhesive Capsulitis of the Shoulder (‘Frozen Shoulder’)ina High Risk Population From the Department ofRheumatology St. George’s Hospital, London. 18November 1980. Q J Med 1981; 50: 191-204

5. Palmer K, Walker-Bone K, Linaker C, Reading I, KellingrayS, Coggon D, Cooper C: The Southampton examinationschedule for the diagnosis of musculoskeletal disorders ofthe upper limb. Annals of the Rheumatic Diseases 2000;59:5-11.

6. Van Der Windt DA, Koes BW, de Jong BA, Bouter LM:Shoulder disorders in general practice: incidence, patientcharacteristics and management. Ann Rheum Dis. 1995;54: 959-964.

7. Mao CY, Jaw WC, Cheng HC: Frozen shoulder: correlationbetween the response to physical therapy and follow-upshoulder arthrography. Arch Phys Med Rehabil. 1997; 78:857-859.

8. Bridgman JF: periarthritis of the shoulder and diabetesmellitus. Ann Rheum Dis. 1972; 31:69-71.

9. Neviaser RJ, Neviaser T: The frozen shoulder Diagnosisand management. Clinical Orthop. Rel Res. 1987; 223: 59-64.

10. Neviaser JS: Adhesive capsulitis of the shoulder: a studyof the pathological findings in periarthritis of the shoulder.J Bone Joint Surgery. 1945; 27: 211-222

11. Hannafin JA, Chiaia TA. Adhesive capsulitis: A treatmentapproach. Clin Orthop Rel Res 2000;372:95–109.

12. Gispen JG. Painful shoulder and reflex sympatheticdystrophy syndrome.In Koopman WJ, ed. Arthritis and AlliedConditions. A Textbook of Rheumatology. Philadelphia:Lippincott Williams & Wilkins 2001: 2095–142.

13. Cyriax JH, editor. Textbook of orthopaedic medicine: Vol.1: Diagnosis of soft tissue lesions. 7th edn. New York:Macmillan Publishing; 1978.

14. Deep Transverse Massage abstract of deep transversefriction’ from the book “A System of Orthopaedic Medicine”.

15. Yang JI, Chang, Chan S, Wang SF, Lin J: Mobilizationtechniques in subjects with frozen shoulder syndrome:Randomized control trial. Phy. Th., 2007, 87(10): 1307-1315

16. MRIwebclinic-February2005.AdhesiveCapsulitisbyMichaelE.Stadnick,M.D.- 16.Walker H. (1984) Deeptransverse frictions in ligament healing. J Orthop SportsPhys Ther 6(2): 89-94

17. Chamberlain G. (1982) Cyriax’s friction massage: A review.J. Orthop Sports Phys Ther 4:16-22

18. De Bruijn R. 1984 Deep transverse friction:its analgesiceffect. International Journal of Sportsmedicine

19. Patterns of motion loss in subjects with idiopathic loss ofshoulder range of motion Clinical Biomechanics, Volume19, Issue 8, Pages 810-818


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